Youth insights on menstrual health and hygiene in Burkina Faso; a comparison of written versus spoken qualitative text

Youth insights on menstrual health and hygiene in Burkina Faso; a comparison of written versus spoken qualitative text | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Youth insights on menstrual health and hygiene in Burkina Faso; a comparison of written versus spoken qualitative text Temidayo Akinreni, Teresa Buitrago-García, N. Hélène Sawadogo, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6837276/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Proper menstrual health and hygiene remains a significant challenge for many schoolgirls in Burkina Faso. Understanding girls’ lived experiences with menstruation is essential, yet can be challenging given the taboo nature of the topic. While diaries have not previously been employed as a data collection method among girls in this setting, the use of diaries could generate unique insights due to their private, reflective, and participant-led nature. Our study aimed to explore the menstrual health and hygiene experiences of schoolgirls in Burkina Faso, comparing diaries and in-person interviews, and to capture girls’ thoughts on the process and value (or lack thereof) of diary writing. Methods This formative study involved 30 girls aged 12–19 years and began with an initial round of in-depth interviews to understand their experiences of menstruation. Participants were then invited to participate in a three-month diary exercise, followed by a second round of in-depth interviews focused on menstruation and the use of diaries. A systematic inductive and deductive approach was used for the analysis, supported by NVivo 12 pro. Results Common social meanings attached to menarche include “becoming a woman” and “staying away from boys”. Some girls said that they or their peers had to avoid cooking, attending festivals, and participating in religious prayers while menstruating. Teasing, stigma, and inadequate water, sanitation, and hygiene facilities were identified as major challenges in schools. For some, the diary provided a safe space to express their thoughts and share their stories about menstruation. However, challenges with diary writing included its additional workload, limitations linked to language proficiency and writing, and perceived repetitive questioning. Diaries and IDIs generated similar menstrual-related themes, indicating that they are equally effective in capturing experiences on this topic among this respondent group in this setting. Conclusions Our study reinforces the need to support schoolgirls in achieving menstrual health and wellbeing. Efforts should prioritize promoting education across communities to mitigate the impact of cultural and religious restrictions. In contexts where participants have limited writing and language proficiency, future studies may consider alternative methods that nevertheless facilitate privacy and are respondent-driven, such as audio diaries. Further research could benefit from adopting either method of data collection to fit the contextual needs of participants. Adolescent Health Diary Menstrual Health and Hygiene Period Teasing Schoolgirls Qualitative Research Background Despite ongoing efforts and interventions channeled to improve menstrual health and hygiene, adolescent girls, especially in resource-limited settings, continue to face substantial challenges [ 1 ]. Research indicates that more than half of menstruating women and girls lack essential resources such as sanitary products and access to proper water, sanitation, and hygiene (WASH) facilities [ 2 ]. This gap has far-reaching health implications, contributing to menstrual and reproductive health issues and heightening the risk of sexual health complications [ 1 , 3 – 5 ]. Like many Sub-Saharan African countries, menstrual health and hygiene remains a major challenge in Burkina Faso. A 2017 national survey revealed that only 26% of women had access to all necessary resources for effective menstrual management [ 6 ]. Studies have also found that approximately two-thirds of women and girls rely on cloth for menstrual health and hygiene [ 6 , 7 ]. While cloth pads are not inherently harmful, improper washing and drying practices, or the use of unclean water, can lead to infections, as found in other studies [ 8 ]. Previous research indicates that some girls skip school when menstruating, particularly in settings where schools lack adequate WASH facilities [ 4 , 9 , 10 ]. In Burkina Faso, 11% of schools provide menstrual waste bins in girls' toilets [ 11 ]. Additionally, social stigmas and teasing – both in and outside of school – can lead to girls withdrawing from education, dropping out, or experiencing feelings of shame and diminished self-esteem [ 4 , 7 , 12 ]. Despite these well-documented barriers, there has been limited exploration of how cultural norms shape attitudes and how such attitudes or understandings affect menstruating schoolgirls in Burkina Faso. This gap in understanding underscores a necessity for a deeper investigation into challenges and cultural dynamics that influence girls’ menstrual hygiene experiences. Traditional qualitative methods, such as interviews and focus groups, have been invaluable in capturing the lived experiences of women and girls dealing with menstrual health and hygiene challenges [ 3 , 13 , 14 ]. However, these methods present limitations, especially when applied to adolescents [ 15 ]. Adolescents may feel uncomfortable discussing sensitive topics in group settings, leading to reticence to share genuine feelings [ 15 , 16 ]. Furthermore, reliance on memory during interviews can result in recall bias, which daily reporting methods, such as diaries, may help mitigate [ 17 ]. To overcome these limitations, researchers in diverse contexts, including high-income countries (HICs) and low- and middle-income countries (LMICs) are increasingly turning to complementary data sources, including diary methods, as a means to collect data on sensitive topics and to determine whether responses varied across different qualitative techniques [ 13 , 18 – 21 ]. Diaries, commonly in the form of paper journals, have been utilized in social and health research [ 22 – 26 ]. Whether solicited (where participants or diarists are provided pre-set prompts) or unsolicited (where they record their experience freely), diaries provides participants with a private space to reflect on sensitive experiences, fostering deeper insights over time [ 27 – 29 ]. Diaries have been effective in exploring sensitive or taboo-related topics such as menstruation and HIV in contexts including Malawi, Namibia, and Kenya [ 13 , 30 – 32 ]. While diary methods have been used in several settings, to date, no studies have investigated their use to explore menstrual health from the perspective of schoolgirls in Burkina Faso. In our study, we delved into the experiences and challenges of menstrual health and hygiene faced by schoolgirls, and we explored their experiences using a solicited diary method. We further explored whether the depth, detail, and emotional expression of menstrual-related responses differed between diary entries and interviews. Methods Study design This formative study was part of a larger qualitative study that sought to examine menstrual health in Nouna, Burkina Faso. The study unfolded across three phases: a baseline phase involving in-depth interviews (IDI) that were focused on participants’ experiences and perspectives on menstruation; next, an extended period (3 months) of solicited diary exercise, allowing participant to document their day-to-day menstrual experiences in real time; and finally, endline IDIs, which not only revisited participants’ views on menstruation but also explored their experiences with using diaries throughout the study (Fig. 1 ). The researchers utilized the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the description and reporting of this study [ 33 ]. (see Supplementary material). Study setting and sampling Our study took place in the northwest region of Boucle de Mouhoun in the Kossi Province (Fig. 2 ). This site was chosen due to the longstanding collaboration between the Nouna Health Research Center and the Heidelberg Institute of Global Health, as well as the limited availability of peer-reviewed literature on menstrual health practices in francophone West Africa. With a focus on schoolgirls, we selected schools that are part of the Nouna’s Health and Demographic Surveillance System (NHDSS). We employed a purposive sampling technique to recruit participants [ 34 ]. Research tools Our research team developed a semi-structured IDI guide and a solicited diary (i.e., with prompts), drawing from a standardized tool developed by UNICEF in 2013 [ 35 ]. Both instruments were originally developed in English and then translated into French, the official language used in schools in Burkina Faso. French-speaking research team members conducted translations and reviewed the tools for accuracy. The IDI guide covered topics such as knowledge of menstruation, societal norms, access to menstrual health and hygiene products, in-school menstrual experience, in-school WASH facilities, and diary reflection. The diary consisted of 11 questions, seven of which focused on menstrual products, four of which centered on participants' overall menstrual experiences. Questions related to menstrual health and hygiene included: “How did you feel when your period came? How would you describe your experience?”, “If you had new doubts, who did you speak with? Why?”, “Did you speak about this topic with friends at school?” “What are your ideas to improve the menstrual experience?”. Both IDI guides and diaries were piloted with schoolgirls from more urban and more rural areas of Nouna, and appropriate refinements, such as adding more space for detailed answers in the diaries, were made. The IDI and diary guides are attached (see Supplementary material). Data collector training Prior to data collection, six researchers in Nouna were recruited, each of whom underwent preparatory training on different aspects of qualitative research. This training included comprehensive sessions on research ethics, qualitative data collection methodologies, and best practices for data debriefing. Data collection Interviews were conducted at two time points. In May 2019, we conducted baseline interviews with 30 girls. Following the completion of these interviews, diaries were distributed, and the girls were guided on how to fill them. By the time of the endline interview three months later, diaries were completed and submitted by 28 out of the 30 girls. A final phase of interviews (n = 25) took place three months later in August 2019, where we asked girls to assess their experience using the diary and to provide follow-up information about their menstrual health and hygiene experiences. During the second phase, five participants were unavailable for follow-up interviews. Data analysis Interviews were audio recorded and transcribed verbatim into French by experienced data transcribers following qualitative standards [ 36 ]. Interview transcripts and diary entries were translated into English and back-translated for quality check and entered into NVivo 12 Pro (QSR International Pty Ltd. Version 12, 2018) for analysis. An inductive and deductive approach guided the analysis. Initially, we established predefined codes based on themes extracted from existing literature [ 37 , 38 ]. Two research members independently coded transcripts, followed by review sessions to compare codes. As new codes or themes emerged from the data, they were discussed and then applied to the entire dataset. Simultaneous review and debriefing sessions ensured data triangulation and consistent data interpretation of diary and IDI data [ 39 ]. Reflexivity In this study, the lead author (TA), a male researcher, and MDCR, a non-binary individual, both of whom have not directly experienced menstruation, recognized the inherent gap in fully grasping the lived experiences of menstruating individuals. Acknowledging this positionality, the collective experience of all authors (TA, TBG, KS, and SAM) in previous menstrual-related studies provided insights into a more comprehensive questioning of menstrual experience and challenges. Grounded in constructivist principles, we embraced the notion that reality is subjective, shaped by individual and societal contexts. This epistemological perspective enabled us to consider several viewpoints on menstruation, therefore enhancing our research. The team’s prior research on menstruation informed the nuanced construction of research instruments but also facilitated a more comprehensive exploration of the complexities surrounding menstrual experiences. Our collaborative, reflexive practice and interdisciplinary experience enhanced our analytical depth and interpretive rigor. Results IDIs lasted 23 to 80 minutes, providing data on the girls' experiences of menarche and menstrual health. The diary exercise lasted three months, with each participant making a minimum of three entries. Each entry averaged between 50 to 120 words, capturing a variety of personal reflections related to menstruation and diary writing experience. Four schoolgirls who were above our initial recruitment age were ultimately recruited because they were actively engaged as students, and the team therefore agreed that their involvement reflected the aim of the research. Pathway of knowledge sharing on menstrual health and hygiene Most girls reported that their primary source of knowledge about menstrual health and hygiene was their mothers in the IDI and diaries. They mentioned common social meanings associated with menarche, such as the need to “stay away from boys”, the notion of “becoming a woman”, and their mothers’ concerns regarding a risk of pregnancy. “(I spoke) with my mother because it is with her that I can speak about things that are about myself. I spoke with her when my first period arrived and she told me “be calm, my child. This is a thing that has meaning for you and other girls, and the meaning is that you are a girl that can have children and there is no problem. She told me to be faithful to myself with boys” (Girl, 17 years, Diary). “[….] (my mother) said when your period comes, that you put to the idea that you can have children, you must not make a relationship with a boy, you must know that you can give birth, that you have become a woman” (Girl, 16 years, IDI). Further insights from the girls revealed that their mothers instilled a strong fear of pregnancy and its potential consequences. “She called me to advise me to be wary of boys, otherwise they can create problems for me. At home when a girl gets pregnant in her dad's yard, her father banishes her and asks her to leave her class, and my mother insisted a lot on that” (Girl, 18 years, IDI) “[....] (my mother) told me not to be afraid that it is my period that is coming, that I have “become a woman”, that she will tell me, that I should not sleep with a man, that even if I go to sleep with a man that I have to monitor my menstrual cycle” (Girl, 16 years, IDI). Upon further probing into what “becoming a woman” meant in their context, girls consistently re-affirmed that becoming a woman implies needing to stay away from boys, and to avoid pregnancy and its consequences (the need to leave school, raise children). We further asked girls about who they speak to if they have any doubts related to menstruation and why they choose to speak to a given person or group. Extracts from the diary showed that girls discuss menstrual-related topics with their mothers. “… if I had doubts, I would tell my mother. She is the first person, the person whom I trust the most. Because she knows everything in life and equally about all her daughters and she takes cares of us, so I would not tell anybody other than her” (Girl, 17 years, Diary). Socio-cultural context around menstruation Stigma associated with menstruation leads to constraints such as having to eat alone, avoiding religious spaces, avoiding public gatherings such as festivals, staying away from certain foods, or refraining from conversing with men about periods. “[..] you must avoid approaching people because you are not clean, some do not accept that you cook. You must be wary of all this. In the public, some people know that you are menstruating, you disgust them, so you must avoid frequenting all these places when you are menstruating.” (Girl, 16 years, IDI) “[…] you must not wander from one place to another to chat with someone, you can sit on a stool that you will stain, or cook, you must avoid this because you are dirty.” (Girl, 15 years, IDI) Furthermore, some participants conveyed that menstruation is perceived as a state of impurity, a view that reflects a stringent interpretation of a religious belief. “Because that's dirt.....everything is dirt, God doesn't like dirt. If you take ablutions with that, it won't be answered, if you pray with it, it will also not be answered.” (Girl, 16 years, IDI) “Among some Muslims, they say that you should not pray if you are on your period, some also say that you should not approach the kitchen” (Girl, 17 years, IDI). This understanding is not restricted to the Muslim community, but also transcends to those of the other faiths, as mentioned by the girls. “There are a lot of things you shouldn't do when you're menstruating. Since if you are on your period even your prayers are not answered, it is many things that you must not do.” (Girl, 18 years, IDI) Some girls described an understanding that praying without the appropriate cleansing during menstruation can be interpreted as an act of defiling God’s name. “It is said in Moré "djènab Koné among traditional worshippers that you are disrespecting god or his name. If you want to purify yourself, you must make an incantation before washing yourself starting with your right side, from the head down, then the left side, and then you can pray otherwise the gods will be angry with you” (Girl, 15 years, IDI). In-school menstrual health and hygiene challenges Period teasing and shame A major challenge girls described in school is the way they are perceived by others, including peers and teachers. Teasing, especially from boys in school, was described as particularly distressing when menstrual blood leaks onto their school uniforms, amplifying their embarrassment and sense of shame. While some girls acknowledged that certain boys were compassionate, experiences of ridicule eclipsed more affirmative exchanges, exacerbating the emotional burden of managing menstruation in a school environment. “There are some boys who understand, but others don't, they don't care. That is all their concern. Even in the city, if they are in the company of their friends and they see you passing by, they talk about it until you hear them. They mock you across the city saying that you can't take care of yourself, that at school, your period flows in everyone's eyes. So, anyone who has the information will be eyeing you in the city, it's shameful. That's how boys are.” (Girl, 15 years, IDI). Teasing extended beyond the school walls, with girls sometimes facing insults from male classmates even in public settings. “They laugh, they insult you, others may even cross you one day in town and talk to you again, some even point out to you that it is this day your cloth was stained” (Girl, 15 years, IDI). While male classmates were described as the most anticipated perpetrators of teasing, female classmates and teachers also shamed girls who failed to adequately hide their menstruation. Stains on clothing are seen as a failure to “take care of oneself”, despite many girls lacking resources to prevent leaks – especially those with heavy menstrual flow. Academic performance and concentration A fear of soiling uniforms weighed heavily on girls, leading to anxiety and diminished focus in class. This distraction occasionally interfered with girls’ ability to concentrate, and in some cases, resulted in humiliation and punishment from teachers. “You can't concentrate anymore because you're afraid. You don't know if you're stained and it's complicated too. If you are in class, you are not happy, because if the teacher question you suddenly, if you refuse to get up, he will not understand and if you are not careful, he can punish you because of this behavior” (Girl, 17 years, IDI). Inadequate WASH facilities Girls in our study highlighted inadequacies of WASH facilities, stressing a need for clean and well-maintained toilets, private and well-equipped changing rooms, and easy access to clean water and soap. In one school, where two or three toilets are shared between boys and girls, these challenges are especially significant for menstruating girls. “You also need a discreet place to throw away your used pads. Inside the toilets, you find everything wet with urine, even the walls, so you don’t even want to go in. It’s not easy.” (Girl, 17 years, IDI) Another participant highlighted privacy concerns associated with inadequate facilities, leaving girls vulnerable to embarrassment and discomfort, especially while changing sanitary pads. “It’s not that simple because our toilets are used by both girls and boys. If you go in to change and you’re not careful, a boy could walk in on you—it’s complicated.” (Girl, 17 years, IDI) Study participants further suggested ways to improve WASH facilities, specifically focusing on improving menstrual health and hygiene in schools. Some of the girls suggested the urgent need for gender-sensitive toilets in schools. “If we could have separate facilities for girls, completely away from the boys' area, it would prevent any contact. Some boys can be quite rude and try to peek inside. It would also be helpful if we could have showers in the toilets.” (Girl, 16 years, IDI) Girls suggestions reflect their desire for improved WASH facilities and demonstrate their advocacy for younger students, particularly their sisters, who may face similar challenges in the future. “[…] building a little house in our school where we can find pads, water, a place where we girls can change, clean ourselves and wear another pad when we are on our period. God would bless you for such a great gesture and we would recognize (thank) you for that. Even if you are not going to do it for us, do it for our little sisters, so that they do not suffer like us. Please?” (Girl, 16 years, Diary) Diary experience: participants’ perspective Beyond exploring menstrual health and hygiene, our qualitative data also captured girls shared experiences using diaries as a research tool (see Table 1 ). Girls reported that diaries enabled them to articulate their thoughts, express themselves freely, share their stories about menstruation, and engage with a taboo topic in a private manner. Furthermore, girls likened diary writing to an experiment that allowed them to explore their ideas. Diary prompts about menarche and menstrual materials particularly resonated with girls, indicating that these topics held significant interest. However, girls faced challenges with written French, along with a perceived repetition of overly-similar questions. Table 1 Participants’ experience with diary Category Sub-category Description Example Facilitators to diary writing Space for ideas and self-expression Participants valued the opportunity to express their thoughts, ideas, and experiences freely through their diary entries, underscoring the role of diary writing as a tool for personal expression and reflection. “…it allows me to express myself and say everything I think about the project” (Girl, 15 years, Diary). “I liked it because I expressed myself about what I experienced. Because you express yourself, you say your ideas, your personal thoughts, so you express everything. It allowed us to say what we ourselves think about menstruation, to free ourselves or to tell stories about our periods and in the second place it allowed us to know about menstruation” (Girl, 22 years, Diary). Increasing familiarity and comfort Participants' acceptance of the journaling task evolved over time. Initial discomfort and reluctance, while not uncommon, gradually gave way to eventual acceptance. “Well, in the first month anyway, I was ashamed to write something, but over time I got used to it” (Girl, 15 years, Diary). Opportunity to engage with a taboo topic Participants highlighted their appreciation for the questions on menarche and types of menstrual materials, emphasizing how the diary provided a valuable space for self-reflection on these often-taboo subjects. “What I liked was the parts about, at what age did you have your first period and how it went, if you suffered from it or not. That's what I liked about this diary” (Girl, 15 years, Diary). Privacy The diary acted as a safe sanctuary, allowing participants to express themselves freely without the fear of judgment or scrutiny from others. “I felt good, you don't need to tell your comments to your friends you can write it in the diary and feel comfortable and only you know about it” (Girl, 15 years, Diary). Barriers to diary writing Limitations of language proficiency and writing A participant’s ability to respond to the diary questions was heavily influenced by their proficiency in French language and their writing skills. While many of the girls spoke French, some found written French to be a limiting factor. For some participants, the questions were straightforward, but others struggled to understand with the complexity of certain prompts, making it challenging to fully express their thoughts. “…the part of ideas and thoughts you have to look for words and formulate with your own French, look for your words, that's not easy” (Girl, 18 years, Diary). “French was a bit difficult to understand” (Girl, 15 years, Diary). “I would like the questions to be asked in simple French, so that the words are not too complicated to understand” (Girl, 15 years, Diary). “The questions weren't difficult, but I was the one who didn't understand. As you also explained there, it's not complicated, if nothing else” (Girl, 18 years, Diary). Added workload Some participants stated that the exercise resembled being assigned a task, as responding to the diary questions required dedicated time for eliciting deeper observations. “It's like I have been given work, because to answer questions, you have to sit down and think, all by yourself to give answers and keep thinking. There are questions that I did not understand” (Girl, 18 years, Diary). “Filling out this diary was very complicated for me, because it had difficult questions to answer” (Girl, 15 years, Diary). Perceived repetition due to probing questions Our data collection team attempted to draw more information through probing questions. However, participants perceived this approach as repetition. “It's the questions that are repeated, you don't know how to answer, you answer here, you turn the page it's pretty much the same question” (Girl, 22 years, Diary). “There are questions that are repeated, that you have already answered, and you do not know what to write. You won't be able to write much anymore because you've said everything before” (Girl, 16 years, Diary). Comparison of IDI and diary methods There was no consistent trend in terms of similarities or differences in responses across the two qualitative methods. For most participants, the level of detail and emotional expression in the diary entries was comparable to that of the IDIs, suggesting that the emotional depth and content in both methods were primarily shaped by individual participant responses rather than by the method itself. In Table 2 , we compare the four menstrual-related questions in the diary entries with those in the IDIs, highlighting how the two methods compared across different participants and topics. Table 2 Comparison of IDI and diary entries among participants Questions/prompts Response in IDI Response in Diary Observation How did you feel when your period came? How would you describe your experience? “I saw this in class, I myself did not know, it was when I arrived home, I see blood now and my stomach started to hurt, I said to myself but what is this? That's how I told my mother, and she has now explained to me what it was.” (Girl, 17 years, IDI) “On the first day of my period, when I got up in the morning I couldn't walk, I had stomach aches, that day, I woke up very early, and I had stomach aches until nine o'clock like that and the periods, it was only the next day that the stomach aches started. That's how it happened.” (Girl, 22 years, IDI) “The day I saw my first period, I was afraid (I had fear), I had never seen that. I asked my mother what was that and my mother responded that it was my period and I still asked how to do to make it end and my mother told me there was nothing to do to make it end. Then my mother gave me the money to go buy (pad brand). When I returned home, she showed me how to protect myself. After that, even if my period comes, I do not need to ask how to protect myself” (Girl, 17 years, Diary). “When my period came, I felt comfortable and ready. During this second month, I would describe my experience: I was a very proud girl and my period was not bothering me anymore. I was free like I wanted.” (Girl, 22 years, Diary) Though similar in content, the diary entry reflects a more positive emotional state and a sense of readiness, while the IDI response describes discomfort and the progression of symptoms. If you had new doubts, who did you speak with? Why? “It was when my period came that I got the information. In any case, it was my mother who gave me the information… I didn't want anyone to know, but in the end I went to tell her, I couldn't get close to my father because I was ashamed of this very thing… She is a woman and knows how it goes, she has the experience and can give you advice on that, on her evolution, that's why I approach her for advice and also, I'm ashamed to talk to my father about it.” (Girl, 17 years, IDI) “(I spoke) with my mother because it is with her that I can speak about things that are about myself. I spoke with her when my first period arrived and she told me “be calm, my child. This is a thing that has meaning for you and other girls, ant the meaning is that you are a girl that can have children and there is no problem (illness scratched)”. She told me to be faithful to myself with boys” (Girl, 17 years, Diary). Both responses are rich in content. We noted no particular difference in response. Did you speak about this topic with friends at school? “No, I don’t know, talking about it is embarrassing…It was the same as the others.” Girl, 15 years, IDI) “Yes, I spoke about this topic with friends at school, they told me that when their period comes, they have abdominal pain. Another one told me something else. Yes, I heard my classmates speak about this topic or about the project. They said that if you have seen your period (if your menarche has arrived), you have to pay attention because you can quickly fall pregnant.” (Girl, 15 years, Diary) The IDI response indicates embarrassment, while the diary entry shows more engagement and information exchange among peers. What are your ideas to improve menstrual experience? “We can talk between girls outside of school hours, to share experiences, you can ask a girl how she will manage if her period occurs while she is in the middle of class, she can tell you that if you have a classmate you can ask her if she has pads or pieces of loincloths in her, and she can give you to protect yourself. But before you get up, if the skirt is stained, as we have black skirts, you can turn the skirt to the side and go out to wear your diapers.” (Girl, 18 years, IDI) “I would like to address girls here that we should not be afraid of speaking about menstruation to our mothers because if we hide the day, we will have problems. I will be too late at that point/moment. Girls should trust their mothers. In case of these types of things, they should not be afraid of speaking to their parents.” (Girl, 18 years, Diary) Both responses suggest improvements but from different perspectives: practical strategies versus communication and trust. Discussion Menstrual health and hygiene experience and challenges Our study highlights how socio-cultural context and in-school challenges shape the menstrual experiences of girls, followed by insights on how girls perceived the diary writing exercise. Girls in our study primarily received limited information on menstruation framed around pregnancy risk and the need to avoid boys. Major challenges identified include cultural and religious restrictions, in-school teasing, and limited WASH facilities. The diary provided a safe space for girls to narrate their experiences and engage in self-expression, although limited writing skills and perceived repetitive questioning were reported. Similar to findings from a comprehensive review and previous studies conducted in Jordan and The Gambia, most girls reported that their primary source of information about menarche was their mothers [ 40 – 42 ]. However, unlike studies in Honduras, Tanzania, and India, where mothers were found to provide accurate and timely information [ 43 – 45 ], our findings indicate limited understanding of the topic. For instance, information they received, such as “It (menstruation) means you are a woman, you have to stay away from boys, you can get pregnant”, reflects how their understanding steeped in cultural beliefs and fears surrounding sexuality [ 46 , 47 ]. This suggests that mothers may view their daughters through a lens of sexual maturation. Findings from a comparable qualitative study in Ethiopia reported that girls are deemed mature for sexual activities once they reach menarche, and such understandings reinforce early sexual debut and out-of-wedlock pregnancies [ 46 ]. Considering rising rates of teenage pregnancy in Burkina Faso in 2022, which surpassed average rates observed in other low-income countries [ 48 ], it is increasingly pertinent to emphasize a need for comprehensive information and support for both girls and their mothers. Challenging negative perceptions of menstruation and fostering open conversations about sexual health remain equally crucial [ 49 – 51 ]. In Burkina Faso, socio-cultural contexts relating to restrictions and stigma remain a major challenge for adolescent girls, hindering existing efforts to improve menstrual health and hygiene practices [ 7 , 12 ]. Our findings resonate with studies conducted in Scotland and The Gambia, which demonstrate that socio-cultural contexts play significant roles in shaping overall menstrual experiences [ 42 , 52 ]. Similar observations were found in Nigeria and Kenya, where menstruating girls and women are prohibited from performing basic household chores, such as cooking [ 13 ], and are discouraged from entering public places [ 53 ]. Such practices contribute to the stigmatization towards menstruating individuals [ 40 , 54 ]. Religious restrictions further exacerbate the challenges surrounding menstruation. For instance, some Muslim participants reported they are prohibited from praying while menstruating, as menstrual blood is considered dirty [ 47 ]. However, this religious restriction is not exclusive to the Muslim community [ 7 , 46 ]. Other religious groups, including indigenous worshippers, shared similar beliefs, with some considering menstruating girls as potentially angering the gods [ 55 , 56 ]. Similarly, a qualitative study reported that women in Fiji, the Solomon Islands, and Papua New Guinea are excluded from participating in religious activities within Christian and Hindu faiths [ 56 ]. There is a prevailing belief that girls must undergo ritual cleansing before they can engage in prayers [ 55 ]. Adopting a faith-based approach may prove insightful to mitigate restrictions. Studies have shown that religious leaders hold a prominent position and voice in their communities [ 57 – 60 ]. Hence, engaging them may be crucial in facilitating a shift in the negative cultural narratives surrounding menstruation [ 57 , 60 ]. Teasing and inadequate WASH facilities proved to be major challenges faced by Burkinabe schoolgirls. Similar findings have been reported from Tanzania and the USA, indicating that girls experience awkward gestures, name-calling, and bullying related to menstruation, suggesting that period teasing is prevalent in schools [ 61 , 62 ]. When subjected to period teasing, girls may experience heightened feelings of shame, guilt, and embarrassment [ 10 ]. Our findings also echoed the results from studies in Kenya, Uganda and Tanzania, which revealed that schoolgirls reported feelings of embarrassment stemming from comments, jokes, and gestures – especially from schoolboys– regarding menstrual leaks or stains [ 63 – 66 ]. These experiences further fueled their feelings of guilt and fear of becoming the target of ridicule among their peers in school [ 64 – 66 ]. Continuous teasing, both inside and outside of school, can significantly impact girls' participation and engagement in various aspects of school life [ 66 ]. In contrast to a study in Kenya, which found adequate facilities for menstrual health and hygiene practice in schools [ 67 ], our participants reported inadequacies in WASH facilities, especially concerning the availability of soap, locks on bathroom doors and water [ 11 , 68 ]. These findings align with another study in Uganda, which emphasized a persistent lack of infrastructural and hygiene facilities, including absence of private toilets for changing and washing, despite several interventions in schools [ 69 ]. The absence of a safe and hygienic environment to address menstrual needs, exacerbates girls’ discomfort and contributes to absenteeism– a detrimental consequence of inadequate WASH facilities [ 70 – 72 ]. Drawing from the results and other LMICs, our study underscores a critical need to implement comprehensive programs in schools that address WASH infrastructure, menstrual health education and anti-bullying and teasing initiatives [ 64 , 73 , 74 ]. Furthermore, a collaborative dialogue that engages girls, parents, religious leaders, teachers, and the wider community, is essential to creating a supportive environment that empowers girls and fosters their confidence in and out of school [ 47 , 75 , 76 ]. Diary insights: participants’ experience, and comparison with IDIs There was no common consensus as to how the girls perceived the diary. For some, the diary writing exercise allowed space for self-expression and the articulation of personal ideas and thoughts, which reflects reports from a book chapter and previous qualitative studies in Turkey and Indonesia [ 23 , 77 , 78 ]. In this sense, diaries can be a tool for personal expression. Through diaries, participants in our study felt a sense of ownership over their narratives, allowing them to share their experiences at their own pace [ 79 , 80 ]. Similar to a qualitative study in the United Kingdom on young people’s alcohol consumption experiences, diaries facilitated engagement with a taboo topic [ 81 ], creating a private space to be candid and alleviating feelings of embarrassment or fear of judgment [ 22 , 81 , 82 ]. In our study, some participants struggled to articulate their thoughts in written French - a challenge that was not identified during the pilot phase of this study. Limited language proficiency and writing skills may lead to feelings of frustration and inhibit participant engagement in diary use [ 83 ]. Previous research has documented how such challenges may foster feelings of frustration and uncertainty about providing new insights [ 84 – 86 ], which underscores the importance of reviewing the diaries at distribution to clarify perceived repetitive or difficult questions [ 19 , 21 ]. Researchers may also explore alternative methods suited to participants' needs, such as audio diaries, among young people with limited language and writing skills [ 25 , 87 , 88 ]. When comparing diary entries to IDIs, we observed no consistent differences in responses across the two methods, which suggests that both methods can yield comparable levels of detail and depth in participants' narratives [ 89 – 91 ]. However, the similarity in content and details we observed in our study may be context-specific and may not necessarily apply to other settings. For instance, qualitative studies in the UK and Kenya reported that diaries provided more detailed and in-depth responses compared to verbal inquiries alone[ 13 , 92 ]. Hence, future research should consider which method, or combination of methods, works best in their specific context. Strengths and limitations By employing solicited diaries and IDIs, our study provided valuable insights into the lived experiences and challenges related to menstrual health and hygiene among schoolgirls in Burkina Faso. Additionally, our study is the first research that explored menstrual health and hygiene utilizing diaries for research in Burkina Faso. However, our sample was limited to urban schools, as logistical difficulties, such as long travel times, flooding, and muddy roads during the rainy season, prevented access to rural areas. Consequently, our findings may not fully represent the experiences of schoolgirls in rural areas. We encourage further research to explore the menstrual experience of schoolgirls in rural areas of Burkina Faso and beyond. Conclusion Our study highlights that schoolgirls received limited information on menstruation framed by fear of pregnancy and avoiding boys. These misconceptions, alongside in-school teasing, sociocultural and religious restrictions, and inadequate WASH facilities, negatively impact their menstrual health experiences. To address these challenges, efforts should focus on improving knowledge and reducing cultural and religious restrictions. Implementing girl-driven, gender-sensitive WASH facilities and integrating menstrual health education into school curricula are essential steps. While diaries may add more content and depth than IDIs in other settings, the methods captured similar themes in our study, suggesting that a multi-method approach may not be necessary for capturing rich qualitative insights within our study context. As interest in alternative data collection methods such as diaries continues to grow, further studies may explore the use of audio diaries in settings where writing skills and language proficiency pose challenges. Abbreviations CRSN Centre de Recherche en Santé de Nouna IDI In-Depth Interview CIE Institutional Ethics Committee NHDSS Nouna Health and Demographic Surveillance Site WASH Water, Sanitation, and Hygiene Declarations Ethical consideration and consent to participate Our study complied with the 2013 Declaration of Helsinki [93], ensuring the protection of participants’ rights, well-being, and confidentiality. This study was approved by the Institutional Ethics Committee (CIE) of the Centre de Recherche en Santé de Nouna (CRSN), Burkina Faso (Ethics approval: 2018-015-/CIE/ CRSN) and the Medical Faculty of the Ruprecht-Karls University of Heidelberg (Ethics approval: S-654/2018). Prior to data collection, we obtained written informed consent from participants aged 17 and older. For participants under age 17, we secured both informed assent and consent of parents or guardians. The data were stored and were only accessible to the study team. Consent for publication Not applicable. Availability of data and materials All data relevant to the study are included in the article or uploaded as supplementary information. Conflict of interest statement The authors declare no conflicts of interest. Funding information This research was supported by the Alexander von Humboldt Foundation, through the Germany’s Federal Ministry of Education and Research (grant number. 405898232). Authors' contributions SAM conceptualized the study, with TB and AS serving as the principal investigators and supervising the research process. SAM, TBG, SL, AS, and TB collaborated on the study design and ethical approval. NHS and TBG conducted data collection under the supervision of SAM, SL, and AS. TA and TBG performed the data analysis. TA wrote the initial draft of the manuscript. TA, TBG, MDCR, NHS, AS, SL, KS, and SAM contributed to the critical review and revision of the manuscript. All authors read and approved the final manuscript. Acknowledgments The authors wish to thank all schoolgirls who participated in this study. We would also like to appreciate our team of data collectors (Méma Sanogo, Clarisse L. Sow, Aoua Drabo, Djénèba Kanazoe, Moussa Ouedraogo, and Yacouba Moukoro) for their invaluable contributions in Nouna, Burkina Faso. References Kuhlmann AS, Henry K, Wall LL. Menstrual Hygiene Management in Resource-Poor Countries. Obstet. Gynecol. Surv. 2017;72:356–76. Hennegan J, Montgomery P. Do Menstrual Hygiene Management Interventions Improve Education and Psychosocial Outcomes for Women and Girls in Low and Middle Income Countries? A Systematic Review. PLOS ONE 2016;11:e0146985. Baku EA, Adrakpanya V, Konlan KD, Adatara P. Menstrual hygiene management among girls at a peri-urban senior high school in the Volta Region, Ghana. Afr. J. Midwifery Womens Health 2020;14:1–12. Keihas L. Menstrual hygiene in schools in two countries of francophone West Africa: Burkina Faso and Niger. 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Hélène Sawadogo","email":"","orcid":"","institution":"Nouna Health Research Centre, Namory Kéita, Nouna, Burkina Faso","correspondingAuthor":false,"prefix":"","firstName":"N.","middleName":"Hélène","lastName":"Sawadogo","suffix":""},{"id":469882717,"identity":"cbe1ac13-4312-46e6-94c8-2347ee33995d","order_by":3,"name":"Aurélia Souares","email":"","orcid":"","institution":"Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Heidelberg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Aurélia","middleName":"","lastName":"Souares","suffix":""},{"id":469882718,"identity":"ed4cae3e-0d2c-4abf-9c40-d45218b80d93","order_by":4,"name":"Mark Donald C Reñosa","email":"","orcid":"","institution":"Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Heidelberg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"Donald C","lastName":"Reñosa","suffix":""},{"id":469882719,"identity":"62b84547-f89b-4618-8364-a14d966be62e","order_by":5,"name":"Kerry Scott","email":"","orcid":"","institution":"School of Global Health, Faculty of Health, York University, Toronto, Canada","correspondingAuthor":false,"prefix":"","firstName":"Kerry","middleName":"","lastName":"Scott","suffix":""},{"id":469882720,"identity":"ebb80e50-c1a7-43b9-9c01-5d9e40937b76","order_by":6,"name":"Ali Sié","email":"","orcid":"","institution":"Nouna Health Research Centre, Namory Kéita, Nouna, Burkina Faso","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Sié","suffix":""},{"id":469882721,"identity":"b4237a75-9502-4ab7-b569-367447376151","order_by":7,"name":"Sarah Langlotz","email":"","orcid":"","institution":"Chair of Development Economics, Georg-August-Universität Göttingen, Göttingen, Germany","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Langlotz","suffix":""},{"id":469882722,"identity":"8d6f5318-5dcb-4a58-9316-3b6db10d37cf","order_by":8,"name":"Till Bärnighausen","email":"","orcid":"","institution":"Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Heidelberg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Till","middleName":"","lastName":"Bärnighausen","suffix":""},{"id":469882723,"identity":"0dc7ed62-eba5-43a2-b231-431c3c34c5f0","order_by":9,"name":"Shannon A McMahon","email":"","orcid":"","institution":"Heidelberg Institute of Global Health, Ruprecht-Karls Universität Heidelberg, Heidelberg, Germany","correspondingAuthor":false,"prefix":"","firstName":"Shannon","middleName":"A","lastName":"McMahon","suffix":""}],"badges":[],"createdAt":"2025-06-06 13:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6837276/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6837276/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101296946,"identity":"081a1a85-6474-4dff-8f4f-61c73591e855","added_by":"auto","created_at":"2026-01-28 09:23:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1014101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6837276/v1/53fa9e9a-370b-4807-af61-d9a785580978.pdf"},{"id":84553682,"identity":"659e48e2-91b2-43aa-be4b-492bdbd29fe6","added_by":"auto","created_at":"2025-06-13 11:01:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":55098,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewToolsVersion1.11.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6837276/v1/7355a6b872ec10a7b1fe86f1.pdf"},{"id":84553685,"identity":"477ee740-45ed-4695-aa2f-1aa9bc793d26","added_by":"auto","created_at":"2025-06-13 11:01:22","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":434987,"visible":true,"origin":"","legend":"","description":"","filename":"20190918JounalFINALEnglish1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6837276/v1/9e6f6ed1afb55cba379e8dd4.pdf"},{"id":84553683,"identity":"37ee96bb-6fe6-4bf1-a211-8bc74f217625","added_by":"auto","created_at":"2025-06-13 11:01:22","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":439673,"visible":true,"origin":"","legend":"","description":"","filename":"COREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6837276/v1/1a0f78a7fa67e67b9a8bad37.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Youth insights on menstrual health and hygiene in Burkina Faso; a comparison of written versus spoken qualitative text","fulltext":[{"header":"Background","content":"\u003cp\u003eDespite ongoing efforts and interventions channeled to improve menstrual health and hygiene, adolescent girls, especially in resource-limited settings, continue to face substantial challenges [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Research indicates that more than half of menstruating women and girls lack essential resources such as sanitary products and access to proper water, sanitation, and hygiene (WASH) facilities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This gap has far-reaching health implications, contributing to menstrual and reproductive health issues and heightening the risk of sexual health complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLike many Sub-Saharan African countries, menstrual health and hygiene remains a major challenge in Burkina Faso. A 2017 national survey revealed that only 26% of women had access to all necessary resources for effective menstrual management [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies have also found that approximately two-thirds of women and girls rely on cloth for menstrual health and hygiene [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While cloth pads are not inherently harmful, improper washing and drying practices, or the use of unclean water, can lead to infections, as found in other studies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious research indicates that some girls skip school when menstruating, particularly in settings where schools lack adequate WASH facilities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Burkina Faso, 11% of schools provide menstrual waste bins in girls' toilets [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, social stigmas and teasing \u0026ndash; both in and outside of school \u0026ndash; can lead to girls withdrawing from education, dropping out, or experiencing feelings of shame and diminished self-esteem [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite these well-documented barriers, there has been limited exploration of how cultural norms shape attitudes and how such attitudes or understandings affect menstruating schoolgirls in Burkina Faso. This gap in understanding underscores a necessity for a deeper investigation into challenges and cultural dynamics that influence girls\u0026rsquo; menstrual hygiene experiences.\u003c/p\u003e \u003cp\u003eTraditional qualitative methods, such as interviews and focus groups, have been invaluable in capturing the lived experiences of women and girls dealing with menstrual health and hygiene challenges [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, these methods present limitations, especially when applied to adolescents [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Adolescents may feel uncomfortable discussing sensitive topics in group settings, leading to reticence to share genuine feelings [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, reliance on memory during interviews can result in recall bias, which daily reporting methods, such as diaries, may help mitigate [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. To overcome these limitations, researchers in diverse contexts, including high-income countries (HICs) and low- and middle-income countries (LMICs) are increasingly turning to complementary data sources, including diary methods, as a means to collect data on sensitive topics and to determine whether responses varied across different qualitative techniques [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiaries, commonly in the form of paper journals, have been utilized in social and health research [\u003cspan additionalcitationids=\"CR23 CR24 CR25\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Whether solicited (where participants or diarists are provided pre-set prompts) or unsolicited (where they record their experience freely), diaries provides participants with a private space to reflect on sensitive experiences, fostering deeper insights over time [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Diaries have been effective in exploring sensitive or taboo-related topics such as menstruation and HIV in contexts including Malawi, Namibia, and Kenya [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile diary methods have been used in several settings, to date, no studies have investigated their use to explore menstrual health from the perspective of schoolgirls in Burkina Faso. In our study, we delved into the experiences and challenges of menstrual health and hygiene faced by schoolgirls, and we explored their experiences using a solicited diary method. We further explored whether the depth, detail, and emotional expression of menstrual-related responses differed between diary entries and interviews.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis formative study was part of a larger qualitative study that sought to examine menstrual health in Nouna, Burkina Faso. The study unfolded across three phases: a baseline phase involving in-depth interviews (IDI) that were focused on participants\u0026rsquo; experiences and perspectives on menstruation; next, an extended period (3 months) of solicited diary exercise, allowing participant to document their day-to-day menstrual experiences in real time; and finally, endline IDIs, which not only revisited participants\u0026rsquo; views on menstruation but also explored their experiences with using diaries throughout the study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The researchers utilized the Consolidated Criteria for Reporting Qualitative Research (COREQ) to guide the description and reporting of this study [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. (see Supplementary material).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting and sampling\u003c/h3\u003e\n\u003cp\u003eOur study took place in the northwest region of Boucle de Mouhoun in the Kossi Province (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This site was chosen due to the longstanding collaboration between the Nouna Health Research Center and the Heidelberg Institute of Global Health, as well as the limited availability of peer-reviewed literature on menstrual health practices in francophone West Africa. With a focus on schoolgirls, we selected schools that are part of the Nouna\u0026rsquo;s Health and Demographic Surveillance System (NHDSS). We employed a purposive sampling technique to recruit participants [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eResearch tools\u003c/h3\u003e\n\u003cp\u003eOur research team developed a semi-structured IDI guide and a solicited diary (i.e., with prompts), drawing from a standardized tool developed by UNICEF in 2013 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Both instruments were originally developed in English and then translated into French, the official language used in schools in Burkina Faso. French-speaking research team members conducted translations and reviewed the tools for accuracy. The IDI guide covered topics such as knowledge of menstruation, societal norms, access to menstrual health and hygiene products, in-school menstrual experience, in-school WASH facilities, and diary reflection. The diary consisted of 11 questions, seven of which focused on menstrual products, four of which centered on participants' overall menstrual experiences. Questions related to menstrual health and hygiene included: \u0026ldquo;How did you feel when your period came? How would you describe your experience?\u0026rdquo;, \u0026ldquo;If you had new doubts, who did you speak with? Why?\u0026rdquo;, \u0026ldquo;Did you speak about this topic with friends at school?\u0026rdquo; \u0026ldquo;What are your ideas to improve the menstrual experience?\u0026rdquo;. Both IDI guides and diaries were piloted with schoolgirls from more urban and more rural areas of Nouna, and appropriate refinements, such as adding more space for detailed answers in the diaries, were made. The IDI and diary guides are attached (see Supplementary material).\u003c/p\u003e\n\u003ch3\u003eData collector training\u003c/h3\u003e\n\u003cp\u003ePrior to data collection, six researchers in Nouna were recruited, each of whom underwent preparatory training on different aspects of qualitative research. This training included comprehensive sessions on research ethics, qualitative data collection methodologies, and best practices for data debriefing.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted at two time points. In May 2019, we conducted baseline interviews with 30 girls. Following the completion of these interviews, diaries were distributed, and the girls were guided on how to fill them. By the time of the endline interview three months later, diaries were completed and submitted by 28 out of the 30 girls. A final phase of interviews (n\u0026thinsp;=\u0026thinsp;25) took place three months later in August 2019, where we asked girls to assess their experience using the diary and to provide follow-up information about their menstrual health and hygiene experiences. During the second phase, five participants were unavailable for follow-up interviews.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eInterviews were audio recorded and transcribed verbatim into French by experienced data transcribers following qualitative standards [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Interview transcripts and diary entries were translated into English and back-translated for quality check and entered into NVivo 12 Pro (QSR International Pty Ltd. Version 12, 2018) for analysis. An inductive and deductive approach guided the analysis. Initially, we established predefined codes based on themes extracted from existing literature [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Two research members independently coded transcripts, followed by review sessions to compare codes. As new codes or themes emerged from the data, they were discussed and then applied to the entire dataset. Simultaneous review and debriefing sessions ensured data triangulation and consistent data interpretation of diary and IDI data [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eIn this study, the lead author (TA), a male researcher, and MDCR, a non-binary individual, both of whom have not directly experienced menstruation, recognized the inherent gap in fully grasping the lived experiences of menstruating individuals. Acknowledging this positionality, the collective experience of all authors (TA, TBG, KS, and SAM) in previous menstrual-related studies provided insights into a more comprehensive questioning of menstrual experience and challenges. Grounded in constructivist principles, we embraced the notion that reality is subjective, shaped by individual and societal contexts. This epistemological perspective enabled us to consider several viewpoints on menstruation, therefore enhancing our research. The team\u0026rsquo;s prior research on menstruation informed the nuanced construction of research instruments but also facilitated a more comprehensive exploration of the complexities surrounding menstrual experiences. Our collaborative, reflexive practice and interdisciplinary experience enhanced our analytical depth and interpretive rigor.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIDIs lasted 23 to 80 minutes, providing data on the girls' experiences of menarche and menstrual health. The diary exercise lasted three months, with each participant making a minimum of three entries. Each entry averaged between 50 to 120 words, capturing a variety of personal reflections related to menstruation and diary writing experience. Four schoolgirls who were above our initial recruitment age were ultimately recruited because they were actively engaged as students, and the team therefore agreed that their involvement reflected the aim of the research.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePathway of knowledge sharing on menstrual health and hygiene\u003c/h2\u003e \u003cp\u003eMost girls reported that their primary source of knowledge about menstrual health and hygiene was their mothers in the IDI and diaries. They mentioned common social meanings associated with menarche, such as the need to \u0026ldquo;stay away from boys\u0026rdquo;, the notion of \u0026ldquo;becoming a woman\u0026rdquo;, and their mothers\u0026rsquo; concerns regarding a risk of pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;(I spoke) with my mother because it is with her that I can speak about things that are about myself. I spoke with her when my first period arrived and she told me \u0026ldquo;be calm, my child. This is a thing that has meaning for you and other girls, and the meaning is that you are a girl that can have children and there is no problem. She told me to be faithful to myself with boys\u0026rdquo; (Girl, 17 years, Diary).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;.] (my mother) said when your period comes, that you put to the idea that you can have children, you must not make a relationship with a boy, you must know that you can give birth, that you have become a woman\u0026rdquo; (Girl, 16 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther insights from the girls revealed that their mothers instilled a strong fear of pregnancy and its potential consequences.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;She called me to advise me to be wary of boys, otherwise they can create problems for me. At home when a girl gets pregnant in her dad's yard, her father banishes her and asks her to leave her class, and my mother insisted a lot on that\u0026rdquo; (Girl, 18 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[....] (my mother) told me not to be afraid that it is my period that is coming, that I have \u0026ldquo;become a woman\u0026rdquo;, that she will tell me, that I should not sleep with a man, that even if I go to sleep with a man that I have to monitor my menstrual cycle\u0026rdquo; (Girl, 16 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUpon further probing into what \u0026ldquo;becoming a woman\u0026rdquo; meant in their context, girls consistently re-affirmed that becoming a woman implies needing to stay away from boys, and to avoid pregnancy and its consequences (the need to leave school, raise children). We further asked girls about who they speak to if they have any doubts related to menstruation and why they choose to speak to a given person or group. Extracts from the diary showed that girls discuss menstrual-related topics with their mothers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; if I had doubts, I would tell my mother. She is the first person, the person whom I trust the most. Because she knows everything in life and equally about all her daughters and she takes cares of us, so I would not tell anybody other than her\u0026rdquo; (Girl, 17 years, Diary).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSocio-cultural context around menstruation\u003c/h2\u003e \u003cp\u003eStigma associated with menstruation leads to constraints such as having to eat alone, avoiding religious spaces, avoiding public gatherings such as festivals, staying away from certain foods, or refraining from conversing with men about periods.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[..] you must avoid approaching people because you are not clean, some do not accept that you cook. You must be wary of all this. In the public, some people know that you are menstruating, you disgust them, so you must avoid frequenting all these places when you are menstruating.\u0026rdquo; (Girl, 16 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] you must not wander from one place to another to chat with someone, you can sit on a stool that you will stain, or cook, you must avoid this because you are dirty.\u0026rdquo; (Girl, 15 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, some participants conveyed that menstruation is perceived as a state of impurity, a view that reflects a stringent interpretation of a religious belief.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Because that's dirt.....everything is dirt, God doesn't like dirt. If you take ablutions with that, it won't be answered, if you pray with it, it will also not be answered.\u0026rdquo; (Girl, 16 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Among some Muslims, they say that you should not pray if you are on your period, some also say that you should not approach the kitchen\u0026rdquo; (Girl, 17 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis understanding is not restricted to the Muslim community, but also transcends to those of the other faiths, as mentioned by the girls.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are a lot of things you shouldn't do when you're menstruating. Since if you are on your period even your prayers are not answered, it is many things that you must not do.\u0026rdquo; (Girl, 18 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome girls described an understanding that praying without the appropriate cleansing during menstruation can be interpreted as an act of defiling God\u0026rsquo;s name.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is said in Mor\u0026eacute; \"dj\u0026egrave;nab Kon\u0026eacute; among traditional worshippers that you are disrespecting god or his name. If you want to purify yourself, you must make an incantation before washing yourself starting with your right side, from the head down, then the left side, and then you can pray otherwise the gods will be angry with you\u0026rdquo; (Girl, 15 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIn-school menstrual health and hygiene challenges\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003ePeriod teasing and shame\u003c/h2\u003e \u003cp\u003eA major challenge girls described in school is the way they are perceived by others, including peers and teachers. Teasing, especially from boys in school, was described as particularly distressing when menstrual blood leaks onto their school uniforms, amplifying their embarrassment and sense of shame. While some girls acknowledged that certain boys were compassionate, experiences of ridicule eclipsed more affirmative exchanges, exacerbating the emotional burden of managing menstruation in a school environment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are some boys who understand, but others don't, they don't care. That is all their concern. Even in the city, if they are in the company of their friends and they see you passing by, they talk about it until you hear them. They mock you across the city saying that you can't take care of yourself, that at school, your period flows in everyone's eyes. So, anyone who has the information will be eyeing you in the city, it's shameful. That's how boys are.\u0026rdquo; (Girl, 15 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTeasing extended beyond the school walls, with girls sometimes facing insults from male classmates even in public settings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They laugh, they insult you, others may even cross you one day in town and talk to you again, some even point out to you that it is this day your cloth was stained\u0026rdquo; (Girl, 15 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile male classmates were described as the most anticipated perpetrators of teasing, female classmates and teachers also shamed girls who failed to adequately hide their menstruation. Stains on clothing are seen as a failure to \u0026ldquo;take care of oneself\u0026rdquo;, despite many girls lacking resources to prevent leaks \u0026ndash; especially those with heavy menstrual flow.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAcademic performance and concentration\u003c/h2\u003e \u003cp\u003eA fear of soiling uniforms weighed heavily on girls, leading to anxiety and diminished focus in class. This distraction occasionally interfered with girls\u0026rsquo; ability to concentrate, and in some cases, resulted in humiliation and punishment from teachers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You can't concentrate anymore because you're afraid. You don't know if you're stained and it's complicated too. If you are in class, you are not happy, because if the teacher question you suddenly, if you refuse to get up, he will not understand and if you are not careful, he can punish you because of this behavior\u0026rdquo; (Girl, 17 years, IDI).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eInadequate WASH facilities\u003c/h2\u003e \u003cp\u003eGirls in our study highlighted inadequacies of WASH facilities, stressing a need for clean and well-maintained toilets, private and well-equipped changing rooms, and easy access to clean water and soap. In one school, where two or three toilets are shared between boys and girls, these challenges are especially significant for menstruating girls.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You also need a discreet place to throw away your used pads. Inside the toilets, you find everything wet with urine, even the walls, so you don\u0026rsquo;t even want to go in. It\u0026rsquo;s not easy.\u0026rdquo; (Girl, 17 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant highlighted privacy concerns associated with inadequate facilities, leaving girls vulnerable to embarrassment and discomfort, especially while changing sanitary pads.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s not that simple because our toilets are used by both girls and boys. If you go in to change and you\u0026rsquo;re not careful, a boy could walk in on you\u0026mdash;it\u0026rsquo;s complicated.\u0026rdquo; (Girl, 17 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudy participants further suggested ways to improve WASH facilities, specifically focusing on improving menstrual health and hygiene in schools. Some of the girls suggested the urgent need for gender-sensitive toilets in schools.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If we could have separate facilities for girls, completely away from the boys' area, it would prevent any contact. Some boys can be quite rude and try to peek inside. It would also be helpful if we could have showers in the toilets.\u0026rdquo; (Girl, 16 years, IDI)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eGirls suggestions reflect their desire for improved WASH facilities and demonstrate their advocacy for younger students, particularly their sisters, who may face similar challenges in the future.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;[\u0026hellip;] building a little house in our school where we can find pads, water, a place where we girls can change, clean ourselves and wear another pad when we are on our period. God would bless you for such a great gesture and we would recognize (thank) you for that. Even if you are not going to do it for us, do it for our little sisters, so that they do not suffer like us. Please?\u0026rdquo; (Girl, 16 years, Diary)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDiary experience: participants\u0026rsquo; perspective\u003c/h2\u003e \u003cp\u003eBeyond exploring menstrual health and hygiene, our qualitative data also captured girls shared experiences using diaries as a research tool (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Girls reported that diaries enabled them to articulate their thoughts, express themselves freely, share their stories about menstruation, and engage with a taboo topic in a private manner. Furthermore, girls likened diary writing to an experiment that allowed them to explore their ideas. Diary prompts about menarche and menstrual materials particularly resonated with girls, indicating that these topics held significant interest. However, girls faced challenges with written French, along with a perceived repetition of overly-similar questions.\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\u003eParticipants\u0026rsquo; experience with diary\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\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eFacilitators to diary writing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpace for ideas and self-expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants valued the opportunity to express their thoughts, ideas, and experiences freely through their diary entries, underscoring the role of diary writing as a tool for personal expression and reflection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;it allows me to express myself and say everything I think about the project\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I liked it because I expressed myself about what I experienced. Because you express yourself, you say your ideas, your personal thoughts, so you express everything. It allowed us to say what we ourselves think about menstruation, to free ourselves or to tell stories about our periods and in the second place it allowed us to know about menstruation\u0026rdquo; (Girl, 22 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncreasing familiarity and comfort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants' acceptance of the journaling task evolved over time. Initial discomfort and reluctance, while not uncommon, gradually gave way to eventual acceptance.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, in the first month anyway, I was ashamed to write something, but over time I got used to it\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpportunity to engage with a taboo topic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParticipants highlighted their appreciation for the questions on menarche and types of menstrual materials, emphasizing how the diary provided a valuable space for self-reflection on these often-taboo subjects.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;What I liked was the parts about, at what age did you have your first period and how it went, if you suffered from it or not. That's what I liked about this diary\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrivacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe diary acted as a safe sanctuary, allowing participants to express themselves freely without the fear of judgment or scrutiny from others.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I felt good, you don't need to tell your comments to your friends you can write it in the diary and feel comfortable and only you know about it\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBarriers to diary writing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimitations of language proficiency and writing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA participant\u0026rsquo;s ability to respond to the diary questions was heavily influenced by their proficiency in French language and their writing skills. While many of the girls spoke French, some found written French to be a limiting factor.\u003c/p\u003e \u003cp\u003eFor some participants, the questions were straightforward, but others struggled to understand with the complexity of certain prompts, making it challenging to fully express their thoughts.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the part of ideas and thoughts you have to look for words and formulate with your own French, look for your words, that's not easy\u0026rdquo; (Girl, 18 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;French was a bit difficult to understand\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I would like the questions to be asked in simple French, so that the words are not too complicated to understand\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The questions weren't difficult, but I was the one who didn't understand. As you also explained there, it's not complicated, if nothing else\u0026rdquo; (Girl, 18 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdded workload\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSome participants stated that the exercise resembled being assigned a task, as responding to the diary questions required dedicated time for eliciting deeper observations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It's like I have been given work, because to answer questions, you have to sit down and think, all by yourself to give answers and keep thinking. There are questions that I did not understand\u0026rdquo; (Girl, 18 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Filling out this diary was very complicated for me, because it had difficult questions to answer\u0026rdquo; (Girl, 15 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived repetition due to probing questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOur data collection team attempted to draw more information through probing questions. However, participants perceived this approach as repetition.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It's the questions that are repeated, you don't know how to answer, you answer here, you turn the page it's pretty much the same question\u0026rdquo; (Girl, 22 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;There are questions that are repeated, that you have already answered, and you do not know what to write. You won't be able to write much anymore because you've said everything before\u0026rdquo; (Girl, 16 years, Diary).\u003c/em\u003e\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=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComparison of IDI and diary methods\u003c/h2\u003e\u003cp\u003eThere was no consistent trend in terms of similarities or differences in responses across the two qualitative methods. For most participants, the level of detail and emotional expression in the diary entries was comparable to that of the IDIs, suggesting that the emotional depth and content in both methods were primarily shaped by individual participant responses rather than by the method itself. In Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, we compare the four menstrual-related questions in the diary entries with those in the IDIs, highlighting how the two methods compared across different participants and topics.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of IDI and diary entries among participants\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\u003eQuestions/prompts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse in IDI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResponse in Diary\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eObservation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow did you feel when your period came? How would you describe your experience?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I saw this in class, I myself did not know, it was when I arrived home, I see blood now and my stomach started to hurt, I said to myself but what is this? That's how I told my mother, and she has now explained to me what it was.\u0026rdquo; (Girl, 17 years, IDI)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;On the first day of my period, when I got up in the morning I couldn't walk, I had stomach aches, that day, I woke up very early, and I had stomach aches until nine o'clock like that and the periods, it was only the next day that the stomach aches started. That's how it happened.\u0026rdquo; (Girl, 22 years, IDI)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;The day I saw my first period, I was afraid (I had fear), I had never seen that. I asked my mother what was that and my mother responded that it was my period and I still asked how to do to make it end and my mother told me there was nothing to do to make it end. Then my mother gave me the money to go buy (pad brand). When I returned home, she showed me how to protect myself. After that, even if my period comes, I do not need to ask how to protect myself\u0026rdquo; (Girl, 17 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;When my period came, I felt comfortable and ready. During this second month, I would describe my experience: I was a very proud girl and my period was not bothering me anymore. I was free like I wanted.\u0026rdquo; (Girl, 22 years, Diary)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThough similar in content, the diary entry reflects a more positive emotional state and a sense of readiness, while the IDI response describes discomfort and the progression of symptoms.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you had new doubts, who did you speak with? Why?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;It was when my period came that I got the information. In any case, it was my mother who gave me the information\u0026hellip; I didn't want anyone to know, but in the end I went to tell her, I couldn't get close to my father because I was ashamed of this very thing\u0026hellip; She is a woman and knows how it goes, she has the experience and can give you advice on that, on her evolution, that's why I approach her for advice and also, I'm ashamed to talk to my father about it.\u0026rdquo; (Girl, 17 years, IDI)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;(I spoke) with my mother because it is with her that I can speak about things that are about myself. I spoke with her when my first period arrived and she told me \u0026ldquo;be calm, my child. This is a thing that has meaning for you and other girls, ant the meaning is that you are a girl that can have children and there is no problem (illness scratched)\u0026rdquo;. She told me to be faithful to myself with boys\u0026rdquo; (Girl, 17 years, Diary).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoth responses are rich in content. We noted no particular difference in response.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid you speak about this topic with friends at school?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;No, I don\u0026rsquo;t know, talking about it is embarrassing\u0026hellip;It was the same as the others.\u0026rdquo; Girl, 15 years, IDI)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I spoke about this topic with friends at school, they told me that when their period comes, they have abdominal pain. Another one told me something else. Yes, I heard my classmates speak about this topic or about the project. They said that if you have seen your period (if your menarche has arrived), you have to pay attention because you can quickly fall pregnant.\u0026rdquo; (Girl, 15 years, Diary)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe IDI response indicates embarrassment, while the diary entry shows more engagement and information exchange among peers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat are your ideas to improve menstrual experience?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We can talk between girls outside of school hours, to share experiences, you can ask a girl how she will manage if her period occurs while she is in the middle of class, she can tell you that if you have a classmate you can ask her if she has pads or pieces of loincloths in her, and she can give you to protect yourself. But before you get up, if the skirt is stained, as we have black skirts, you can turn the skirt to the side and go out to wear your diapers.\u0026rdquo; (Girl, 18 years, IDI)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;I would like to address girls here that we should not be afraid of speaking about menstruation to our mothers because if we hide the day, we will have problems. I will be too late at that point/moment. Girls should trust their mothers. In case of these types of things, they should not be afraid of speaking to their parents.\u0026rdquo; (Girl, 18 years, Diary)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBoth responses suggest improvements but from different perspectives: practical strategies versus communication and trust.\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"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eMenstrual health and hygiene experience and challenges\u003c/h2\u003e \u003cp\u003eOur study highlights how socio-cultural context and in-school challenges shape the menstrual experiences of girls, followed by insights on how girls perceived the diary writing exercise. Girls in our study primarily received limited information on menstruation framed around pregnancy risk and the need to avoid boys. Major challenges identified include cultural and religious restrictions, in-school teasing, and limited WASH facilities. The diary provided a safe space for girls to narrate their experiences and engage in self-expression, although limited writing skills and perceived repetitive questioning were reported.\u003c/p\u003e \u003cp\u003eSimilar to findings from a comprehensive review and previous studies conducted in Jordan and The Gambia, most girls reported that their primary source of information about menarche was their mothers [\u003cspan additionalcitationids=\"CR41\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. However, unlike studies in Honduras, Tanzania, and India, where mothers were found to provide accurate and timely information [\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], our findings indicate limited understanding of the topic. For instance, information they received, such as \u0026ldquo;It (menstruation) means you are a woman, you have to stay away from boys, you can get pregnant\u0026rdquo;, reflects how their understanding steeped in cultural beliefs and fears surrounding sexuality [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. This suggests that mothers may view their daughters through a lens of sexual maturation. Findings from a comparable qualitative study in Ethiopia reported that girls are deemed mature for sexual activities once they reach menarche, and such understandings reinforce early sexual debut and out-of-wedlock pregnancies [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Considering rising rates of teenage pregnancy in Burkina Faso in 2022, which surpassed average rates observed in other low-income countries [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], it is increasingly pertinent to emphasize a need for comprehensive information and support for both girls and their mothers. Challenging negative perceptions of menstruation and fostering open conversations about sexual health remain equally crucial [\u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Burkina Faso, socio-cultural contexts relating to restrictions and stigma remain a major challenge for adolescent girls, hindering existing efforts to improve menstrual health and hygiene practices [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our findings resonate with studies conducted in Scotland and The Gambia, which demonstrate that socio-cultural contexts play significant roles in shaping overall menstrual experiences [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Similar observations were found in Nigeria and Kenya, where menstruating girls and women are prohibited from performing basic household chores, such as cooking [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and are discouraged from entering public places [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Such practices contribute to the stigmatization towards menstruating individuals [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eReligious restrictions further exacerbate the challenges surrounding menstruation. For instance, some Muslim participants reported they are prohibited from praying while menstruating, as menstrual blood is considered dirty [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. However, this religious restriction is not exclusive to the Muslim community [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Other religious groups, including indigenous worshippers, shared similar beliefs, with some considering menstruating girls as potentially angering the gods [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. Similarly, a qualitative study reported that women in Fiji, the Solomon Islands, and Papua New Guinea are excluded from participating in religious activities within Christian and Hindu faiths [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. There is a prevailing belief that girls must undergo ritual cleansing before they can engage in prayers [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Adopting a faith-based approach may prove insightful to mitigate restrictions. Studies have shown that religious leaders hold a prominent position and voice in their communities [\u003cspan additionalcitationids=\"CR58 CR59\" citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Hence, engaging them may be crucial in facilitating a shift in the negative cultural narratives surrounding menstruation [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTeasing and inadequate WASH facilities proved to be major challenges faced by Burkinabe schoolgirls. Similar findings have been reported from Tanzania and the USA, indicating that girls experience awkward gestures, name-calling, and bullying related to menstruation, suggesting that period teasing is prevalent in schools [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. When subjected to period teasing, girls may experience heightened feelings of shame, guilt, and embarrassment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Our findings also echoed the results from studies in Kenya, Uganda and Tanzania, which revealed that schoolgirls reported feelings of embarrassment stemming from comments, jokes, and gestures \u0026ndash; especially from schoolboys\u0026ndash; regarding menstrual leaks or stains [\u003cspan additionalcitationids=\"CR64 CR65\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. These experiences further fueled their feelings of guilt and fear of becoming the target of ridicule among their peers in school [\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. Continuous teasing, both inside and outside of school, can significantly impact girls' participation and engagement in various aspects of school life [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast to a study in Kenya, which found adequate facilities for menstrual health and hygiene practice in schools [\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e], our participants reported inadequacies in WASH facilities, especially concerning the availability of soap, locks on bathroom doors and water [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e]. These findings align with another study in Uganda, which emphasized a persistent lack of infrastructural and hygiene facilities, including absence of private toilets for changing and washing, despite several interventions in schools [\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e]. The absence of a safe and hygienic environment to address menstrual needs, exacerbates girls\u0026rsquo; discomfort and contributes to absenteeism\u0026ndash; a detrimental consequence of inadequate WASH facilities [\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e]. Drawing from the results and other LMICs, our study underscores a critical need to implement comprehensive programs in schools that address WASH infrastructure, menstrual health education and anti-bullying and teasing initiatives [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e]. Furthermore, a collaborative dialogue that engages girls, parents, religious leaders, teachers, and the wider community, is essential to creating a supportive environment that empowers girls and fosters their confidence in and out of school [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eDiary insights: participants\u0026rsquo; experience, and comparison with IDIs\u003c/h2\u003e \u003cp\u003eThere was no common consensus as to how the girls perceived the diary. For some, the diary writing exercise allowed space for self-expression and the articulation of personal ideas and thoughts, which reflects reports from a book chapter and previous qualitative studies in Turkey and Indonesia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e]. In this sense, diaries can be a tool for personal expression. Through diaries, participants in our study felt a sense of ownership over their narratives, allowing them to share their experiences at their own pace [\u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e80\u003c/span\u003e]. Similar to a qualitative study in the United Kingdom on young people\u0026rsquo;s alcohol consumption experiences, diaries facilitated engagement with a taboo topic [\u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e], creating a private space to be candid and alleviating feelings of embarrassment or fear of judgment [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e81\u003c/span\u003e, \u003cspan citationid=\"CR82\" class=\"CitationRef\"\u003e82\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, some participants struggled to articulate their thoughts in written French - a challenge that was not identified during the pilot phase of this study. Limited language proficiency and writing skills may lead to feelings of frustration and inhibit participant engagement in diary use [\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e83\u003c/span\u003e]. Previous research has documented how such challenges may foster feelings of frustration and uncertainty about providing new insights [\u003cspan additionalcitationids=\"CR85\" citationid=\"CR84\" class=\"CitationRef\"\u003e84\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e], which underscores the importance of reviewing the diaries at distribution to clarify perceived repetitive or difficult questions [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Researchers may also explore alternative methods suited to participants' needs, such as audio diaries, among young people with limited language and writing skills [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e87\u003c/span\u003e, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e88\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen comparing diary entries to IDIs, we observed no consistent differences in responses across the two methods, which suggests that both methods can yield comparable levels of detail and depth in participants' narratives [\u003cspan additionalcitationids=\"CR90\" citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]. However, the similarity in content and details we observed in our study may be context-specific and may not necessarily apply to other settings. For instance, qualitative studies in the UK and Kenya reported that diaries provided more detailed and in-depth responses compared to verbal inquiries alone[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e]. Hence, future research should consider which method, or combination of methods, works best in their specific context.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003e By employing solicited diaries and IDIs, our study provided valuable insights into the lived experiences and challenges related to menstrual health and hygiene among schoolgirls in Burkina Faso. Additionally, our study is the first research that explored menstrual health and hygiene utilizing diaries for research in Burkina Faso. However, our sample was limited to urban schools, as logistical difficulties, such as long travel times, flooding, and muddy roads during the rainy season, prevented access to rural areas. Consequently, our findings may not fully represent the experiences of schoolgirls in rural areas. We encourage further research to explore the menstrual experience of schoolgirls in rural areas of Burkina Faso and beyond.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlights that schoolgirls received limited information on menstruation framed by fear of pregnancy and avoiding boys. These misconceptions, alongside in-school teasing, sociocultural and religious restrictions, and inadequate WASH facilities, negatively impact their menstrual health experiences. To address these challenges, efforts should focus on improving knowledge and reducing cultural and religious restrictions. Implementing girl-driven, gender-sensitive WASH facilities and integrating menstrual health education into school curricula are essential steps. While diaries may add more content and depth than IDIs in other settings, the methods captured similar themes in our study, suggesting that a multi-method approach may not be necessary for capturing rich qualitative insights within our study context. As interest in alternative data collection methods such as diaries continues to grow, further studies may explore the use of audio diaries in settings where writing skills and language proficiency pose challenges.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRSN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentre de Recherche en Sant\u0026eacute; de Nouna\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-Depth Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCIE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInstitutional Ethics Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNHDSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNouna Health and Demographic Surveillance Site\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, Sanitation, and Hygiene\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical consideration and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study complied with the 2013 Declaration of Helsinki [93], ensuring the protection of participants\u0026rsquo; rights, well-being, and confidentiality. This study was approved by the Institutional Ethics Committee (CIE) of the Centre de Recherche en Sant\u0026eacute; de Nouna (CRSN), Burkina Faso (Ethics approval: 2018-015-/CIE/ CRSN) and the Medical Faculty of the Ruprecht-Karls University of Heidelberg (Ethics approval: S-654/2018). Prior to data collection, we obtained written informed consent from participants aged 17 and older. For participants under age 17, we secured both informed assent and consent of parents or guardians. The data were stored and were only accessible to the study team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data relevant to the study are included in the article or uploaded as supplementary information.\u003c/p\u003e\n\u003cp\u003eConflict of interest statement\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the\u0026nbsp;Alexander von Humboldt Foundation, through the Germany\u0026rsquo;s Federal Ministry of Education and Research (grant number. 405898232).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSAM conceptualized the study, with TB and AS serving as the principal investigators and supervising the research process. SAM, TBG, SL, AS, and TB collaborated on the study design and ethical approval. NHS and TBG conducted data collection under the supervision of SAM, SL, and AS. TA and TBG performed the data analysis. TA wrote the initial draft of the manuscript. TA, TBG, MDCR, NHS, AS, SL, KS, and SAM contributed to the critical review and revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all schoolgirls who participated in this study. We would also like to appreciate our team of data collectors (M\u0026eacute;ma Sanogo, Clarisse L. Sow, Aoua Drabo, Dj\u0026eacute;n\u0026egrave;ba Kanazoe, Moussa Ouedraogo, and Yacouba Moukoro) for their invaluable contributions in Nouna, Burkina Faso. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKuhlmann AS, Henry K, Wall LL. 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Risk and worry in everyday life: Comparing diaries and interviews as tools in risk perception research. Health Risk Soc. 2009;11:209\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects | Research, Methods, Statistics | JAMA | JAMA Network [Internet]. 2013 [cited 2024 Dec 9];Available from: https://jamanetwork.com/journals/jama/fullarticle/1760318\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Adolescent Health, Diary, Menstrual Health and Hygiene, Period, Teasing, Schoolgirls, Qualitative Research","lastPublishedDoi":"10.21203/rs.3.rs-6837276/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6837276/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProper menstrual health and hygiene remains a significant challenge for many schoolgirls in Burkina Faso. Understanding girls\u0026rsquo; lived experiences with menstruation is essential, yet can be challenging given the taboo nature of the topic. While diaries have not previously been employed as a data collection method among girls in this setting, the use of diaries could generate unique insights due to their private, reflective, and participant-led nature. Our study aimed to explore the menstrual health and hygiene experiences of schoolgirls in Burkina Faso, comparing diaries and in-person interviews, and to capture girls\u0026rsquo; thoughts on the process and value (or lack thereof) of diary writing.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis formative study involved 30 girls aged 12\u0026ndash;19 years and began with an initial round of in-depth interviews to understand their experiences of menstruation. Participants were then invited to participate in a three-month diary exercise, followed by a second round of in-depth interviews focused on menstruation and the use of diaries. A systematic inductive and deductive approach was used for the analysis, supported by NVivo 12 pro.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCommon social meanings attached to menarche include \u0026ldquo;becoming a woman\u0026rdquo; and \u0026ldquo;staying away from boys\u0026rdquo;. Some girls said that they or their peers had to avoid cooking, attending festivals, and participating in religious prayers while menstruating. Teasing, stigma, and inadequate water, sanitation, and hygiene facilities were identified as major challenges in schools. For some, the diary provided a safe space to express their thoughts and share their stories about menstruation. However, challenges with diary writing included its additional workload, limitations linked to language proficiency and writing, and perceived repetitive questioning. Diaries and IDIs generated similar menstrual-related themes, indicating that they are equally effective in capturing experiences on this topic among this respondent group in this setting.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur study reinforces the need to support schoolgirls in achieving menstrual health and wellbeing. Efforts should prioritize promoting education across communities to mitigate the impact of cultural and religious restrictions. In contexts where participants have limited writing and language proficiency, future studies may consider alternative methods that nevertheless facilitate privacy and are respondent-driven, such as audio diaries. Further research could benefit from adopting either method of data collection to fit the contextual needs of participants.\u003c/p\u003e","manuscriptTitle":"Youth insights on menstrual health and hygiene in Burkina Faso; a comparison of written versus spoken qualitative text","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 11:01:18","doi":"10.21203/rs.3.rs-6837276/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c649f08-ce01-4797-8062-8f8bf84a6cc7","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-27T15:57:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-13 11:01:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6837276","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6837276","identity":"rs-6837276","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}