Gender Equity in Menstrual Health: Challenges in Product Access and Disposal Among Adolescent Girls in Lusaka, Zambia

Gender Equity in Menstrual Health: Challenges in Product Access and Disposal Among Adolescent Girls in Lusaka, Zambia | 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 Gender Equity in Menstrual Health: Challenges in Product Access and Disposal Among Adolescent Girls in Lusaka, Zambia Joy Sambo, Sikopo Nyambe, Yoshiko Hashimoto Kondo, Taro Yamauchi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6346873/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Access to reproductive health services is crucial for the empowerment and well-being of women and girls in low-, middle-, or high-income countries, particularly in Menstrual Health and Hygiene Management. Despite global progress in menstrual health advocacy, disparities in menstrual product access, usage and disposal persist, especially in low-resource settings. Adolescent girls in the peri-urban Lusaka, Zambia, face significant sanitary product affordability, access, and disposal infrastructure challenges. Additionally, cultural perceptions and societal stigmas further shape menstrual health experiences, influencing both product access and disposal behaviors. Methods Employing a mixed-methods cross-sectional approach, menstruators from one Government school in Peri-urban Lusaka (n = 266) aged 12–19 were surveyed alongside participants (n = 24) from different grades (5–9), purposively sampled from various peri-urban communities, and in focus group discussions, contributing to an essential discourse on health service access. Data were analysed using JMP Pro and MAXQDA 10 after triangulation with other researchers. Results Quantitative findings revealed a marked preference for disposable menstrual products (85%), with users reporting higher levels of comfort and convenience. Supermarkets and retailers accounted for 94% of the product supply, while others sourced available homemade materials. Menstrual. In contrast, reusable products were utilised primarily by households with lower economic means, where accessibility and cost were significant factors. Statistical analysis indicated a strong correlation between education level and preferred product type, highlighting that increased awareness leads to a stronger inclination towards sustainable options. Qualitative insights from focus groups underscored the influence of cultural beliefs on menstrual management. Participants often transported waste home for discreet disposal, reflecting a cultural understanding of managing waste while identifying inadequate disposal facilities outside the house. Thematic analysis identified key cultural narratives that prioritise discretion and comfort but overlook environmental and health considerations, revealing gaps in knowledge that can hinder adequate reproductive health access. Conclusion Our research reveals significant disparities in the availability and acceptance of menstrual products, highlighting the roles of social stigma, educational opportunities, and environmental considerations. Enhancing access to culturally relevant menstrual health resources can significantly advance gender equity in reproductive health access. Findings suggest critical avenues for culturally sensitive interventions that provide access to appropriate menstrual products and foster educational programs about environmental impacts and health implications. By addressing these cultural dynamics and enhancing the availability of hygiene facilities, we can significantly improve girls’ experiences and promote gender equity in reproductive health. Interventions in reproductive health must include service delivery and more access to quality products for vulnerable populations like adolescent girls. Adolescents Disposal Practices Reproductive Health Menstrual Health Menstrual Product Access Lusaka-Zambia 1. Introduction Menstrual health is a critical yet often overlooked component of reproductive health that significantly impacts the well-being of women and girls. Access to menstrual products and safe disposal methods is essential for maintaining hygiene, enabling education, and promoting gender equity. Adolescent girls face numerous challenges: limited access to menstrual products, good hygiene practices, and limited knowledge. Disposable sanitary products are widely used for convenience, comfort, volume, protection, duration of blood absorption, and accessibility [ 1 , 2 ] despite environmental impacts [ 2 ]. Inadequate water, disposal, private changing facilities and materials in Low- and Middle-Income Countries (LMICs) leave menstruating girls with limited options for healthy personal hygiene during menstruation. School facilities impact girls’ dignity, well-being, and performance [ 3 ]. Poor Menstrual Health and Hygiene (MHH) affects the health of millions of adolescents in Sub-Saharan Africa (SSA), as socioeconomic constraints influence product accessibility challenges[ 4 ] and preferences. Access to safe water supply, hygiene, facilities and affordable products are crucial. Menstruators need access to sufficient products that can absorb blood safely, comfortably, and discreetly, supporting sustainable use [ 5 ]. A prominent, persistent issue is a struggle to afford sufficient materials [ 9 ] In LMICs, girls experience poor menstruation due to limited reproductive health access, knowledge, and stigma, reinforcing harmful taboos that may negatively affect their health and well-being. This is further compounded by limited guidance on menstrual management. Notably, most adolescents only learn about menstruation at menarche, embedded in cultural beliefs [ 6 , 7 ]. Accessibility to hygienic and culturally acceptable materials is key in addressing taboos and practices [ 5 ]. Product knowledge, usage, and affordability can influence the use of alternative reusable materials, like washable cloth and period underwear [ 8 ]. Inaccurate menstrual knowledge is a great hindrance, as girls face difficulties, whether at school or home [ 8 ]. Menstrual waste, an essential component of MHH, is challenging in many LMICs, mainly due to poor waste collection systems, taboos, and superstitions surrounding menstruation [ 8 ]. The limited disposal infrastructure also challenges waste management. Menstrual products swell as they absorb menstrual blood, contributing to blocked and clogged pipes if inappropriately discarded, in toilets and sewega systems. Menstruators manage waste differently at home and outside, trashing it or flushing it in toilets without knowing the consequences of choking, environmental effects, and associated health hazards [ 9 ]. Menstrual waste is regarded as taboo waste to be dealt with discreetly, not in the public eye [ 5 ]. Sanitation workers hate removing menstrual waste from blocked sewage as it is annoying, disgusting, and hazardous [ 10 ]. Improperly disposed waste requires treatment [ 11 ], thus making sustainable solid waste management a problem, even for workers, if not correctly handled [ 12 ]. Disposable products are widely used[ 1 , 2 ] despite environmental impacts of waste [ 2 ].The environmental impact increases as menstruators often dispose of waste inappropriately in toilets and pit latrines for fear of not being seen by others, for privacy and discreteness. Lack of culturally acceptable disposal infrastructure also affects school Water, Sanitation and Hygiene (WASH) facilities [ 13 ]. In peri-urban settings, inadequate access to WASH, sanitary materials, and insufficient disposal infrastructure remains a challenge. Despite global advances in menstrual health advocacy, inequities in access to menstrual education and services remain stark, especially within school systems. Menstrual health is often treated as a girls-only issue. This gendered silence reinforces stigma, perpetuates myths, and isolates menstruating girls. Furthermore, while many low- and middle-income countries are developing or updating school health and WASH policies, menstrual health is still not always clearly addressed or consistently implemented. These gaps highlight both a global and local failure to integrate MHH into broader reproductive health and gender equity frameworks, a failure that manifests acutely in school settings, including in Zambia. This study investigates the complex interplay of various factors and the cultural perceptions influencing girls’ menstrual product access and disposal practices. Focusing on understanding and addressing the health disparities within the context of gender equity in reproductive health, significantly impacts reproductive health access among girls. Specifically, the research objectives included (i) examining the relationship of factors affecting menstrual product choices, and sources, (ii) investigating the impact of factors like household income to product access, and (iii) exploring the menstrual waste disposal practices used, to understand the environmental implications and potential human health hazards. This paper sheds light on the cultural beliefs surrounding menstrual health in Lusaka and the implications for accessing reproductive health services. Limited research has explored the intersection of socioeconomic, cultural, and environmental factors in shaping menstrual practices and reproductive healthcare access.. 2. Methods Study population and location This was a mixed-methods study of adolescent girls in peri-urban Lusaka City. The targeted population was menstruating adolescent schoolgirls between 10–19 years old. The inclusion criteria was participants who had reached menarche (experienced their first menstruation) and were less than 19 years old. Based on the Government school's management recommendation, we targeted one class each from the 5th to 9th grade. The school was located in one of the densely populated peri-urban areas, near the central business centre, and is attended by girls from several other peri-urban communities. Quantitative Data A cross-sectional design was used to collect socio-demographic data, product preferences and disposal practices of menstrual management. Purposive sampling was used to select menstruators and lower and upper primary participants from the school who met the survey requirements. 400 participants were surveyed, and only 266 provided sufficient data to facilitate analysis. A questionnaire survey was created after an extensive literature review on socio-demographics, socio-economic status, product choice, and menstrual waste disposal practices. Descriptive statistics and further analysis were conducted to interpret the data. Age was divided into two groups based on median age to reveal differences in trends. Product access were categorised as disposable or reusable, with various disposal methods. Multivariable logistic regression analysis was used to identify the determinants of menstrual product preferences and disposal options while controlling for potential confounders. The stepwise regression technique was used to select the best predictive model. Qualitative Data FGDs with 24 menstruating girls from the same school aged 12 to 19, representing various peri-urban communities were included using convenience sampling. The focus groups of 8 girls per group lasted for about 90 minutes and explored girls' experiences with product preference and usage, disposal practices, and cultural beliefs surrounding health access. Thematic analysis was performed using MAXQDA 10, with triangulation with three other researchers reinforcing the findings' reliability. Ethical Considerations This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki, which ensures the protection, dignity, and rights of all research participants. The Ethics Review Committee of the Faculty of Health Sciences, Hokkaido University (No. 2011-0001) reviewed and approved the study protocols and methods. After a thorough briefing on the study, all participants provided informed consent. For girls under 18, informed assent was obtained from parents or guardians per Zambia’s legal age of consent. 3. Results The findings are based on quantitative and qualitative data. The quantitative data addresses the factors affecting menstrual product access, menstrual waste disposal, and environmental implications. The qualitative data addresses product access, usage, and health concerns and later reveals Waste Disposal Practices And Access To Disposal Facilities. 3.1 Quantitative: Factors Affecting Menstrual Product Access The median age was 15.0 years (Inter-Quartile Range = 14–16 years), with 61% attending junior secondary school, sharing similar language and cultural practices (Table 1 ). Table 1 Socio-demographic characteristics of adolescent schoolgirls (n = 266) Characteristic n (%) Age 15 years and below 181 (68) 16 years and above 86 (32) Age at menarche 15 years and below 254 (95) 16 years and above 5 (2) Unknown 7 (3) Education Level Grade 5–7 (Primary) 104 (39) Grade 8–9 (Junior Secondary) 163 (61) Region (province) groups Northern 140 (52) Eastern 69 (26) Western 58 (22) Household Monthly Income* $ 50 and below 55 (21) $ 50 to $ 100 20 (8) $ 100 and above 8 (3) Missing 183 (69) Household Head Both parents 63 (24) Father 45 (17) Mother 113 (42) Guardian 28 (11) Missing 0. (6)] *1 Zambian kwacha for $ 0.11 US dollar (Exchange rate on 25/12/2022). In this study, menstrual absorbent products refer to sanitary pads and cotton wool, whereas reusable products refer to cloth and washable pads. Out of those surveyed, about 67% of girls aged 15 years and below preferred disposable sanitary products like pads and baby diapers. Most participants (99%) sourced disposable materials from local shops and supermarkets. Chi-square analysis showed an association between absorbent materials and the kind of variables: education level (0.0141) attained, product source (0.0001) used, and waste disposal method (0.041) practised ( Table 2 ). Table 2 Menstrual product access and participant characteristics Menstrual absorbent material p-value Disposable (n = 227) Reusable (n = 39) Age n (%) n (%) 15 years and below 151 (66.52) 28 (71.79) 0.517 16 years and above 76 (33.48) 11 (28.21) Education Level Grade 5–7 (Primary) 81 (35.68) 22 (56.41) 0.0141* Grade 8–9 (Secondary) 146 (64.32) 17 (43.59) Ethnic Region Eastern 60 (26.43) 9 (23.08) 0.534 Northern 121 (53.30) 19 (48.72) Western 46 (20.26) 11 (28.21) Household Income $ 50 and below 44 (19.38) 11 (28.21) 0.346 $ 50 to $ 100 23 (10.13) 5 (12.82) Missing 160 (70.48) 23 (58.97) Household Income Source Both parents 54 (23.79) 9 (23.08) 0.889 Father 40 (17.62) 5 (12.82) Mother 95 (41.85) 18 (46.15) Other 38 (16.74) 7 (17.95) Product Source Self-made 3 (1.32) 13 (33.33) < .0001* Shop/Supermarket 224 (98.68) 26 (66.67) Waste Disposal Method Burn and bury 102 (46.79) 11 (28.95) 0.041* Pit latrine and flushing toilet 116 (53.21) 27 (71.05) Sanitary Products Monthly Expense $ 1 dollar and below 127 (55.95) 19 (48.72) 0.090 More than $ 1 dollar 43 (18.94) 4 (10.26) Missing 57 (25.11) 16 (41.03) Frequency of changing materials daily Once or twice 108 (47.58) 19 (48.72) 0.895 Three times and more 119 (52.42) 20 (51.28) * Significant p-value 2 **1 Zambian kwacha for $ 0.11 US dollar (Exchange rate on 25/12/2022). From the logistic regression analysis, the source of products was a significant predictor of the type of product used after controlling the level of education. The chances of the schoolgirls using disposable products were 34 times higher for commercially sourced than home-made products (Adjusted Odds Ratio/AOR) 33.99; 95% CI: 8.98–128.56) (Table 3 ). From multivariable logistic regression, eligible independent factors for menstrual choices were education level and product source. The access to material showed an association with participants’ education and where they sourced their products. Table 3 Logistic regression analysis of factors contributing to menstrual product access. Characteristics Menstrual product type AOR (95% CI) Disposable (n = 227) Reusable (n = 39) Education Level n (%) n (%) Grade 5–7 (Primary) 81 (35.68) 22 (56.41) 1 Grade 8–9 (Secondary) 146 (64.32) 17 (43.59) 1.96 (0.90–4.26) Product Source Self-made 3 (1.32) 13 (33.33) 1 Shop/Supermarket 224 (98.68) 26 (66.67) 33.99 (8.98-128.56) 3.2 Qualitative: Product Access, Usage And Health Concerns For qualitative data on product access, the following framing question was used to identify themes, sub-themes, and codes on product access: what product(s) do you use and why? The first theme addressed the menstrual product(s) used. The sub-themes included preferences, accessibility, and affordability. The codes included pads with wings and diapers, shops and stores, and expensive and alternative products. The second theme addressed the reason for the product(s) used. The sub-themes were health and safety. The codes were rash, itchiness, fungal infections, menstrual pain, safety concerns and perceived chemicals in diapers when cut into two or three pieces. Themes, sub-themes, and codes are shown below. Th Theme Su Sub-theme Co Codes 1. Menstrual product Accessibility and its Impact on Choice • Preferences • Accessibility • Affordability • Pads with wings; Diapers • Shops, stores • Expensive; alternative product 2.Reason for usage and health concerns • Health • Rash, itchy, fungal infections, pain • Safety; chemicals Theme 1: Menstrual Product Accessibility and its Impact on Access Most girls preferred disposable materials like pads with wings to securely hold underwear or used baby diapers that were cheaper to buy as a single piece, not the whole pack. However, reasons for accessing particular products included: “I choose disposable napkins for their comfort, especially since they have wings to hold onto the pants and tape to remain attached. The cloth napkins do not have tape on the wings or bottom. I always fear that it will fall off and embarrass me.” (13 years) “Disposable pads are the best options; even if we use diapers sometimes, they are not as good as pads” (12 years) “Normally, one to two sanitary packs are enough. My parents buy for me when buying household goods if I’m lucky.” (13 years) Additionally, baby diapers were used to drain blood because of their wider surface area and affordability. Girls faced challenges accessing products; participants used reusable materials available at home for reuse or disposal as desired. “I use disposable sanitary napkins or baby diapers and reusable sanitary cloth.” (15 years). “I also use some leftover napkins and use washable clothes or ask my sisters or mother if they have any left.” (14 years) “I have used diapers before. I do not like them, but my mother forces me to use them. When she doesn’t have enough money, I add my savings to buy pads since diapers are easy for others to see that you are menstruating (protrude due to big size) (16 years) Theme 2: Reason for usage and health concerns Some girls cited various health concerns influencing their menstrual product preferences, particularly expressing worries about the quality of available products. Specifically, those using cut diapers as makeshift pads were apprehensive about potential skin reactions and itching due to direct contact with the powdery substances inside. While some girls found diapers to be better, others disagreed. Some health concerns highlighted included “We use disposable napkins because they are effective. However, they give rash or other vaginal reactions.” (15 years). “I am worried about the diapers’ white particles on my skin (cotton dust after cutting diapers to make several pieces to drain blood)” (13 years) “Ummm, I don’t use cotton wool. I find it difficult to use” (14 years) Surprisingly, many girls were unaware that schools offered menstrual materials for students experiencing menstruation. Despite the school providing necessary resources and a supportive environment, this lack of awareness resulted in underutilisation and access to such essential services. 3.3 Quantitative: Menstrual Waste Disposal Practices Disposal methods included burying, burning, pit latrine or flush toilets, and throwing in a waste bin. For disposal practices, eligible independent factors were household income source and product used. About 69% did not know their household income and came from homes headed (42%) by mothers. The age at menarche (15.0 years) was similar to the median age (Table 4 ). Table 4 Menstrual waste disposal methods used among schoolgirls. Characteristics Waste disposal practice* p-value Burn and bury (n = 113) Pit latrine and Flush toilet (n = 143) Age n (%) n (%) 15 years and below 79 (69.91) 91 (63.64) 0.291 16 years and above 34 (30.09) 52 (36.36) Age at menarche 15 years and below 108 (95.58) 138 (96.50) 0.759 16 years and above 2 (1.77) 3 (2.10) Unknown 3 (2.65) 2 (1.40) Education Level Grade 5–7 (Primary) 36 (31.86) 60 (41.96) 0.097 Grade 8–9 (Secondary) 77 (68.14) 83 (58.04) Ethnic Region (province) groups Eastern 28 (24.78) 40 (27.97) 0.422 Northern 56 (49.56) 76 (53.15) Western 29 (25.66) 27 (18.88) Household Monthly Income** $ 50 and below 31 (70.45) 24 (61.54) 0.097 $ 50 to $ 100 13 (29.55) 15 (38.46) Unknown 69 (61.06) 104 (72.73) Household Income Source Both parents 17 (15.04) 45 (31.47) 0.009*** Father 21 (18.58) 23 (16.08) Mother 51 (45.13) 59 (41.26) Other 24 (21.24) 16 (11.19) Product Source Self-made 2 (1.77) 12 (8.39) 0.021*** Shop/Supermarket 111 (98.23) 131 (91.61) Monthly expense on sanitary products One dollar and less 27 (23.89) 20 (13.99) 0.123 More than one dollar 58 (51.33) 85 (59.44) Unknown 28 (24.78) 38 (26.57) Frequency of changing sanitary towels daily Once or twice 57 (50.44) 64 (44.76) 0.365 Three times and more 56 (49.56) 79 (55.24) *Multiple responses allowed for waste disposal practice. 2** Zambian kwacha for $ 0.11 US dollar (Exchange rate on 25/12/2022). 3*** Significant factor Table 4 shows that most (64%) girls aged 15 years and below disposed of sanitary absorbent materials in pit latrines or flush toilets compared to girls (36%) who were 16 years and above. On the education level, girls (58%) at the secondary education level used latrines and toilets for disposal, and girls (42%) at the primary level. Household income source results showed that 73% of the girls did not know their household income, and mothers were the most cited household income source (41%). Chi-square analysis revealed associations between waste disposal practice and three other variables: household income (0.097), household income source (0.009), and product source (0.021), indicating that the significant independent predictors were the source of household income and the type of product used (AOR = 2.29, 95% CI: 1.06–4.95) (Table 5 ). Table 5 Logistic regression analysis of factors associated with waste disposal practices Characteristics Waste disposal practice* AOR (95% CI) Burn and Bury (n = 113) Pit latrine and Flush toilet (n = 143) Household Income Source n (%) n (%) Both parents 17 (15.04) 45 (31.47) 1 Father 21 (18.58) 23 (16.08) 2.38 (1.05–5.42) Mother 51 (45.13) 59 (41.26) 2.34 (1.19–4.6) Other 24 (21.24) 16 (11.19) 4.18 (1.78–9.82) Menstrual Product Used Reusable products 11 (9.73) 27 (18.88) 1 Disposable products 102 (90.27) 116 (81.12) 2.29 (1.06–4.95) *p < 0.05 3.4 Qualitative: Waste Disposal Practices And Access To Disposal Facilities The framing question addressed appropriate disposal methods for qualitative waste disposal and facility access results. The first theme addressed disposal locations. The three sub-themes included rinsing off the blood before disposal, throwing, burying or burning and the waste handling procedures. The three corresponding codes were safety and home, discreet and private, and mistrust and evil. The second theme addressed the reason for the preferred disposal methods used. The three sub-themes included cultural beliefs, the disposal options taught, and ideal practices. The corresponding codes were private and hygiene, knowledge and home, preferred and safe. Themes, sub-themes, and codes are shown below. Theme Sub-theme Codes 3.Sociocultural Perceptions of menstrual waste disposal • Rinsing off the blood before • Throw, bury or burn • Waste handling process • Safety; home • Discreet; private • Mistrust; evil 4.Preferred disposal methods and their influence on practices • Cultural beliefs • Disposal options taught • Ideal practices • Private, hygiene • Knowledge; home • Preferred; safe Theme 3: Sociocultural Perceptions of Menstrual Waste Disposal Most schoolgirls did not dispose of waste at school. Instead, waste was wrapped in paper or plastic to be carried and disposed of at home after school. Girls preferred to dispose of used materials at home, fearing that evil people would use their menstrual blood to bewitch them. With such superstitions and beliefs about waste, it isn't easy to implement WASH facilities if girls’ perceptions and needs are culturally sensitive: “At school, we carry the used napkins back home wrapped in plastic bags” (12 years). “We want a toilet (pit latrine) that we can use to throw pads in.” (13 years) “A trash bin is not ideal at all. I have never thrown in the school. We do not want bins in the school or public places at all. I can only use the bin at home by hiding the waste under other household waste” (14 years). Theme 4: Preferred disposal methods and their influence on practices Girls found it challenging to manage menstrual waste at school. At home, some girls used a pit latrine, burned materials, or rinsed the blood before throwing the garbage in the trash bins. Others mentioned concerns about whom and how their waste is handled at school. Unsafe and lacked sanitary materials: “As for me, rinsing off blood from the napkins and later throwing them away in the bin is the best option” (15 years). “Just throwing away the used napkin in the bins is not ideal or good, especially at school where we do not know how the materials will be handled later” (14 years). “The pit latrine is the best. We also dig a hole in the ground to throw away waste. I do not throw away in the trash as others may get the pads from the trash and use them for evil things” (13 years). All the girls preferred changing materials at home. Some girls revealed that the school toilets were dirty. Some cited practices included: “I do not change pads from school; I always go home where I feel safe.” (13 years) “No, I do not change, I wait until I get home” (12 years) “Throwing away from home, in a trash bin, is good. Even if they put bins in school, we can’t use them” (15 years). 4. Discussion 4.1 Factors Affecting Menstrual Products Access This study focuses on the experiences and practices of menstrual management of Zambian schoolgirls, where girls reached menarche from 13–15 years old [ 14 ]. A study conducted in Blantyre, Malawi, surveyed 258 women about their sociodemographic characteristics, menstrual absorbent choices, and disposal practices [ 15 ] and revealed similar practices to those in the present study. Interestingly, girls' experiences and practices in Bangladesh were similar to Zambia and Malawi [ 16 ]. This suggests that practices on menstrual management of adolescent girls are similar regardless of geographical location and socioeconomic status [ 17 ]. Menstrual product choices are affected by accessibility, affordability, reliability, comfort and convenience. Despite financial challenges, girls commonly used disposable absorbent materials for their comfort and absorbency; alternatively, they used cotton wool, baby diapers, and cloth pads. Most girls want to be comfortable and confident that their chosen product will perform well [ 18 , 19 ]. A product’s performance measure is the ability to protect girls from leakages and associated embarrassment [ 20 , 21 ]. A study in Zambia highlighted how school boys, for instance, shame and embarrass girls once they gain knowledge of any of the girls’ particular menstrual days, and worse off, if any ‘menstrual accident’ or leaks happens while at school [ 21 ]. Also, girls experience fear and anxiety due to harassment from male peers [ 21 ]. A study in Zimbabwe showed that product choice and consumption go beyond provision—external environmental factors such as access to water, soap, sanitary facilities, and sociocultural factors also influence decision-making [ 22 ]. In addition, comprehensive education and accurate knowledge are critical in combating gender bias and stigma [ 23 ]. Therefore, girls must be comfortable with the products used, especially when their male counterparts are present at school. Ultimately, affordability, convenience, durability and socio-cultural factors affect the choices. 4.2 Factors Impacting Product Access, Usage And Health Concerns Schoolgirls' household income impacted their materials, despite their preference for commercial and disposal products due to their ease and suitability. Interestingly, girls also used baby diapers as pads and bought them as a single diaper at about $ 0.11 from local retailers and shops. Diapers were easily accessible as a single piece for unanticipated periods without purchasing an entire pack, as with pads, which proved less costly. Access to affordable materials is among the health disparities among lower-income girls [ 24 ]. Also, diapers provided a larger surface area for girls with heavy menstrual flow. Alas, diapers being bigger pose a more significant threat to sewage systems and the environment if disposed of in toilets [ 12 , 25 ]. Girls need to be educated and sensitised about the implications of waste disposal, especially in toilets. Most girls preferred disposable sanitary products with wings and tape for secure attachment to underwear despite financial challenges in accessing quality products. The economic status was crucial, with some girls opting for reusable materials sourced from home due to constraints [ 25 ]. Few participants in focus groups used cotton wool due to the tendency to soil quickly, tearing off, and lack of secure attachment. Girls’ sources of materials differed, and access did not translate to affordability. Product choices were influenced by availability, product knowledge, and social expectations [ 18 ]. Girls emphasised that products must be accessible, affordable, culturally acceptable [ 22 ], and comfortable to support sustainable use and environmental safety. Alternative products like menstrual cups and washable absorbent materials have recently become popular due to their environmental and cost benefits [ 22 ]. A study in Zambia that introduced menstrual cups revealed that cups are not commonplace, are perceived to cause cancer or injury to the reproductive organs, and, in some cases, result in loss of virginity. Interestingly, the study also revealed that participants desired to use cups as an alternative product after product and information access [ 26 ]. However, menstrual cups may not be culturally appropriate in some regions, where inserting anything into the vagina is taboo for unmarried girls due to concerns and fear about virginity. Misconceptions about cup hymen breakage and sexual dissatisfaction persist [ 27 ]. In some cultures, there are also fears about fertility [ 28 ]. Interestingly, despite these challenges, girls showed interest and a need for more awareness about cups. Cultural beliefs significantly impact menstrual choices [ 5 ], along with socio-economic factors, product safety, acceptability, and menstrual knowledge. 4.3 Menstrual Waste Disposal And Environmental Implications The waste disposal methods included burning, burying, pit latrines, flush toilets and waste bins,. Studies in Malawi show that most menstrual waste is thrown in pit latrines or burned [ 15 ]. These practices threaten the sanitary sewage system, human health, and the environment. Some girls rinsed the blood off before throwing waste in bins, like in Indonesia [ 29 ]. Other girls also stated concerns about whom and how waste is handled if disposed of at school, implying a lack of trust and uncertainty about who and how people other than themselves handle their ‘sacred’ waste. Participants used several methods while expressing the need to learn more about sustainable methods and the implications of their practices. In Zambia, sustainable solid waste management remains challenging in peri-urban areas due to rapid population growth, unplanned sanitary facilities, and inadequate service provision. Sewage systems were blocked due to waste like pads and diapers. A Lusaka study revealed that most of the solid waste generated in the urban areas was not collected and disposed of at designated sites. Solid waste treatment was conducted at minimal rates and was not sustainable [ 12 ]. Similarly, in India, waste was disposed of in toilets without knowing the consequences of blockage [ 25 ]. 4.4 Waste Disposal Practices And Access To Disposal Facilities Most girls preferred pit latrines and were unaware of the environmental issues of sewage blockages or time taken to decompose. Most participants were unaware of the amount of plastic in disposable products [ 18 ]. Cultural myths and taboos surrounding waste are also prevalent, as some girls were not utilising municipal garbage collection services unless materials were hidden or blood washed off beforehand, as observed among schoolgirls in Indonesia [ 29 ]. Culture and religion can influence practices when discreetness with waste handling is encouraged, and it may have adverse effects if inadequate knowledge is lacking. Sociocultural factors significantly influenced product choice and disposal practices. Beliefs and teachings about menstruation influenced these practices. Menstruators need access to private, safe, and convenient disposal options that support sustainable use. A Zambian study revealed that throwing used menstrual materials in toilets was ideal for fear of others mishandling waste for witchcraft practices that may result in menstruators experiencing stomach pains or infertility [ 21 ]. Similar beliefs about menstrual waste being sacred and fear of evil people were cited in our focus groups. Poor knowledge of best disposal practices linked to cultural beliefs has significant environmental impacts. The school environment itself lacked the necessary facilities to manage menstruation despite the girls’ desire to utilise them. Therefore, menstrual education, provision of female-friendly toilets with locks on doors, water within stalls, and menstrual disposal options are needed in school WASH infrastructures [ 16 , 21 ]. Menstrual waste remains a neglected MHH and sanitation value chain issue, impacting users, the sanitation systems and the environment [ 30 ]. The lack of acceptable and culturally sensitive disposal infrastructure, menstrual awareness, and social stigma can contribute to unending improper disposal practices. Personal and sociocultural factors and WASH facilities affect the girls' practices and the environment. Our study builds on previous research to explain materials and waste disposal practices in LMICs [ 30 ]. The available facilities, knowledge, and cultural myths influenced the disposal practices. Strengths And Limitations One limitation of the study is using purposive sampling with a relatively small sample size. While purposive sampling enabled us to target girls with relevant characteristics, it limits the generalizability of findings. Nonetheless, this limitation is offset by several strengths of our study. The sampling allowed us to obtain in-depth and detailed qualitative data, providing rich insights into the phenomena under investigation. Moreover, our study addresses a significant gap in the current literature by focusing on an understudied population or phenomenon, adding valuable new knowledge to the field. Additionally, we employed rigorous methodological practices to ensure the reliability and validity of our data through triangulation. 5. Conclusion Our study investigated factors affecting reproductive healthcare access of menstrual materials, disposal and environmental impacts. Firstly, our analysis reveals that menstrual product access among adolescent schoolgirls is influenced by education level and the sources of materials. Most participants preferred disposable materials for comfort, durability, and convenience. Additionally, some girls used baby diapers as a cost-effective alternative for wider absorbency surface area. Household income was also crucial in determining access to quality absorbent materials. While some households prioritised buying menstrual materials, others did not, resulting in MHH disparities and barriers to accessing required materials to manage menstruation. Cultural beliefs influenced disposal practices. For instance, although the school provided sanitary waste bins, they remained underutilised due to cultural teachings regarding the sacred nature of menstrual waste. Consequently, girls carried their waste home, most discarding waste in pit latrine toilets without considering the environmental impacts. The findings underscore the necessity of providing culturally acceptable and sensitive disposal options and facilities. Such measures are essential to creating MHH-friendly facilities and promoting educational equity and advancement. Novelty And International Relevance This study contributes novel perspectives by identifying the sociocultural factors and infrastructural constraints in peri-urban Lusaka to inform context-specific interventions that enhance menstrual equity and strengthen reproductive healthcare service access. In moving toward menstrual equity, it is essential to recognise that cultural beliefs and gender norms profoundly shape how menstruation is experienced and managed. Respecting cultural sensitivities does not mean avoiding the conversation; instead, it means engaging communities in ways that honour their values while protecting health and dignity. Inclusive menstrual education involving accurate knowledge of products and disposal and incorporating both girls and boys in the discourse, paired with context-sensitive infrastructure and policy support, can reduce stigma and foster understanding. 6. Future Research and Policy Implications These findings also highlight deeper systemic inequities within school-based reproductive health education. While some schools provide menstrual products, the lack of awareness among girls reflects a communication gap. More critically, the exclusion of boys from menstrual health education perpetuates stigma and reinforces harmful gender norms. Globally, MHH is often framed as a private, female concern, leaving boys uneducated and girls unsupported. This unequal distribution of information contributes to reproductive health inequities, as girls bear the burden of secrecy and shame. In Zambia, like in many settings, school health policies lack explicit guidance on integrating MHH into comprehensive reproductive health education for all students. Addressing this silence through inclusive, gender-transformative education could help dismantle stigma and promote shared responsibility in menstrual health. Importantly, the exclusion of boys from menstrual health education contributes to a broader inequity in reproductive health knowledge. While boys may not require menstrual products, their lack of accurate information perpetuates teasing, misunderstanding, and a culture of silence that directly affects girls’ dignity and safety at school. This creates an unequal emotional and social burden for menstruating students, placing the responsibility of discretion, coping, and shame solely on girls. Promoting inclusive menstrual health education—without breaching cultural sensitivities—can help cultivate mutual respect, reduce stigma, and shift school environments toward greater gender equity. Declarations Declaration of Interest statement The authors have nothing to declare. Funding Sources Our research activities were supported by: (i) “The Sanitation Value Chain: Designing Sanitation Systems as Eco-Community Value System” Project, Research Institute for Humanity and Nature (RIHN, Project No.14200107), and (ii) No. 22489817). Author Contribution JS wrote the main manuscript, and SN edited and revised it. TY provided the methods, supervision and proofreading. YHK helped in the analysis and re-arranging of materials. All authors revised the manuscript and authorised the final draft. Acknowledgement We want to thank all study participants, school management in Zambia, the Sanitation Value Chain (SVC), colleagues from the Africa-Japan Collaborative Research (AJ-CORE: COCO WASH) project, Hokkaido University, my colleague Jessy Ruth Z'gambo, my husband and mentor Mwape Chitupa, my children, friends and family. References Luchese CL, Engel JB, Tessaro IC. Disposable, reusable and biodegradable hygiene products. Antimicrobial Textiles from Natural Resources, Elsevier; 2021. pp. 421–54. Tu J-C, Lo T-Y, Lai Y-T. Women’s Cognition and Attitude with Eco-Friendly Menstrual Products by Consumer Lifestyle. Int J Environ Res Public Health. 2021;18:5534. Phillips-Howard PA, Caruso B, Torondel B, et al. Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities. Glob Health Action. 2016;9:33032. Anbesu EW, Asgedom DK. Menstrual hygiene practice and associated factors among adolescent girls in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health 2023;23. Sambo J, Nyambe S, Yamauchi T. A qualitative study on menstrual health and hygiene management among adolescent schoolgirls in peri-urban Lusaka. Zambia J Water Sanitation Hygiene Dev. 2024;14:15–26. Padmanabhanunni A, Fennie T. The menstruation experience: Attitude dimensions among South African students. J Psychol Afr. 2017;27:54–60. Alexander K, Oduor C, Nyothach E, et al. Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls? Water (Basel). 2014;6:1453–66. Atari DO, Tariquzzaman SK, Nancy A. Knowledge and Perceptions on Menstrual Hygiene Management Among School-Going Adolescent Girls in South Sudan. J Adolesc Res 2021:074355842110432. Kaur R, Kaur K, Kaur R. Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries. J Environ Public Health. 2018;2018. Sai A, Furqan RAL, Ushijima K, et al. Physical and Mental Health of Sanitation Workers in an Urban Slum of Indonesia: Personal Hygiene and the Construction of Self-Esteem in. Waste-Handling. 2021;5:26–027. Chandra-Mouli V, Patel SV. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health 2017;14. Sambo J, Muchindu M, Nyambe S, et al. Sustainable Solid Waste Management: An Assessment of Solid Waste Treatment in Lusaka, Zambia. Sanitation Value Chain. 2020;4:39–050. Wilmouth R, Muller N, Truyens C et al. Interactions between menstrual hygiene management and sanitation systems: Landscape analysis of menstrual hygiene products and a waste-loading model. 2013. Lahme AM, Stern R, Cooper D. Factors impacting on menstrual hygiene and their implications for health promotion. Glob Health Promot. 2018;25:54–62. Roxburgh H, Magombo C, Kaliwo T, et al. Blood flows: mapping journeys of menstrual waste in Blantyre, Malawi. Cities Health. 2022;6:738–51. Connolly S, Sommer M. Cambodian girls’ recommendations for facilitating menstrual hygiene management in school. J Water Sanitation Hygiene Dev. 2013;3:612–22. Ha MAT, Alam MdZ. Menstrual hygiene management practice among adolescent girls: an urban–rural comparative study in Rajshahi division, Bangladesh. BMC Womens Health. 2022;22:86. Peberdy E, Jones A, Green D. A Study into Public Awareness of the Environmental Impact of Menstrual Products and Product Choice. Sustainability. 2019;11:473. Sommer M, Torondel B, Hennegan J et al. How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals. Glob Health Action 2021;14. Davidson A. Narratives of Menstrual Product Consumption. Bull Sci Technol Soc. 2012;32:56–70. Chinyama J, Chipungu J, Rudd C, et al. Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls. BMC Public Health. 2019;19:16. Tembo M, Renju J, Weiss HA, et al. Menstrual product choice and uptake among young women in Zimbabwe: a pilot study. Pilot Feasibility Stud. 2020;6:182. Zablock K, Fei YF. Young Men’s Attitudes and Understanding of Menstruation. J Adolesc Health. 2024;74:782–6. Davies S, Darien K, Wood S, et al. 79. A Multimodal Approach to Understanding the Barriers and Facilitators to Adolescent Menstrual Health Equity. J Adolesc Health. 2022;70:S41–2. Kaur R, Kaur K, Kaur R. Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries. J Environ Public Health. 2018;2018:1–9. Gondwe M, Simuyaba M, Phiri M, et al. Acceptability of and experiences with menstrual hygiene cups among adolescent girls and young women aged 15–24 in two communities in Lusaka, Zambia: an exploratory study nested in the Yathu Yathu trial. Reprod Health. 2025;22:20. Kambala C, Chinangwa A, Chipeta E, et al. Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi. Reprod Health. 2020;17:185. Pokhrel D, Bhattarai S, Emgård M, et al. Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study. Reprod Health. 2021;18:20. Sato K, Hamidah U, Ikemi M, et al. Menstruation and Menstrual Hygiene Management: A Case Study of Adult Females in an Urban Slum of Indonesia. Sanitation Value Chain. 2021;5:83–097. Elledge M, Muralidharan A, Parker A, et al. Menstrual Hygiene Management and Waste Disposal in Low and Middle Income Countries—A Review of the Literature. Int J Environ Res Public Health. 2018;15:2562. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 19 May, 2026 Reviews received at journal 02 Jul, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers agreed at journal 02 May, 2025 Reviewers agreed at journal 25 Apr, 2025 Reviewers agreed at journal 24 Apr, 2025 Reviewers invited by journal 24 Apr, 2025 Editor assigned by journal 04 Apr, 2025 Submission checks completed at journal 01 Apr, 2025 First submitted to journal 31 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6346873","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":448417399,"identity":"94e0ec99-1f12-4233-878d-c8108f64c4ad","order_by":0,"name":"Joy Sambo","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Joy","middleName":"","lastName":"Sambo","suffix":""},{"id":448417400,"identity":"da20a093-cc12-4790-8d96-3777647e88ce","order_by":1,"name":"Sikopo Nyambe","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Sikopo","middleName":"","lastName":"Nyambe","suffix":""},{"id":448417401,"identity":"460f5fc2-1993-4121-b247-71df79b712ce","order_by":2,"name":"Yoshiko Hashimoto Kondo","email":"","orcid":"","institution":"Hokkaido University","correspondingAuthor":false,"prefix":"","firstName":"Yoshiko","middleName":"Hashimoto","lastName":"Kondo","suffix":""},{"id":448417402,"identity":"e687fb9d-ab6b-4c27-a8cb-2b5c96afc8e1","order_by":3,"name":"Taro Yamauchi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYNCCCiA+wMPA2MDAzMAGFuHBrRgidYZkLYxtSFoIAnv2sw8f887bJsd3gPfgw5lt1vJ8DMwPPzDI3MFtC0+6sTHvttvGkgf4kg03tqUbtjGwGUsw8DzD47A0NmmglsQNB3jMJB+2HQY50gwofhi3Fv5nQC1zbtfDtNi3MbB/w69FAmRLw+0EA5CWjW2HE9sYeAjYcuMZs+GcY7cNZx7mMTaccS49uY2Zp1giAY9f2PvTGB+8qbktz3e8x/BhT5m17fz29o0fPvbgDjEQYAJHDjxGQIzEngN4tTD+wBT7gV/LKBgFo2AUjCgAAFckT3RpENivAAAAAElFTkSuQmCC","orcid":"","institution":"Hokkaido University","correspondingAuthor":true,"prefix":"","firstName":"Taro","middleName":"","lastName":"Yamauchi","suffix":""}],"badges":[],"createdAt":"2025-03-31 17:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6346873/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6346873/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81521245,"identity":"b5723636-ed61-4791-97b4-6aebe69e06f5","added_by":"auto","created_at":"2025-04-28 08:05:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1530338,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6346873/v1/f65427a6-9a7e-4b0a-9c70-87c22f3a3a12.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gender Equity in Menstrual Health: Challenges in Product Access and Disposal Among Adolescent Girls in Lusaka, Zambia","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMenstrual health is a critical yet often overlooked component of reproductive health that significantly impacts the well-being of women and girls. Access to menstrual products and safe disposal methods is essential for maintaining hygiene, enabling education, and promoting gender equity. Adolescent girls face numerous challenges: limited access to menstrual products, good hygiene practices, and limited knowledge. Disposable sanitary products are widely used for convenience, comfort, volume, protection, duration of blood absorption, and accessibility [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] despite environmental impacts [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInadequate water, disposal, private changing facilities and materials in Low- and Middle-Income Countries (LMICs) leave menstruating girls with limited options for healthy personal hygiene during menstruation. School facilities impact girls\u0026rsquo; dignity, well-being, and performance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Poor Menstrual Health and Hygiene (MHH) affects the health of millions of adolescents in Sub-Saharan Africa (SSA), as socioeconomic constraints influence product accessibility challenges[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and preferences. Access to safe water supply, hygiene, facilities and affordable products are crucial. Menstruators need access to sufficient products that can absorb blood safely, comfortably, and discreetly, supporting sustainable use [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A prominent, persistent issue is a struggle to afford sufficient materials [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn LMICs, girls experience poor menstruation due to limited reproductive health access, knowledge, and stigma, reinforcing harmful taboos that may negatively affect their health and well-being. This is further compounded by limited guidance on menstrual management. Notably, most adolescents only learn about menstruation at menarche, embedded in cultural beliefs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Accessibility to hygienic and culturally acceptable materials is key in addressing taboos and practices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Product knowledge, usage, and affordability can influence the use of alternative reusable materials, like washable cloth and period underwear [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Inaccurate menstrual knowledge is a great hindrance, as girls face difficulties, whether at school or home [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMenstrual waste, an essential component of MHH, is challenging in many LMICs, mainly due to poor waste collection systems, taboos, and superstitions surrounding menstruation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The limited disposal infrastructure also challenges waste management. Menstrual products swell as they absorb menstrual blood, contributing to blocked and clogged pipes if inappropriately discarded, in toilets and sewega systems. Menstruators manage waste differently at home and outside, trashing it or flushing it in toilets without knowing the consequences of choking, environmental effects, and associated health hazards [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMenstrual waste is regarded as taboo waste to be dealt with discreetly, not in the public eye [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Sanitation workers hate removing menstrual waste from blocked sewage as it is annoying, disgusting, and hazardous [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Improperly disposed waste requires treatment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], thus making sustainable solid waste management a problem, even for workers, if not correctly handled [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Disposable products are widely used[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] despite environmental impacts of waste [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].The environmental impact increases as menstruators often dispose of waste inappropriately in toilets and pit latrines for fear of not being seen by others, for privacy and discreteness. Lack of culturally acceptable disposal infrastructure also affects school Water, Sanitation and Hygiene (WASH) facilities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In peri-urban settings, inadequate access to WASH, sanitary materials, and insufficient disposal infrastructure remains a challenge.\u003c/p\u003e \u003cp\u003eDespite global advances in menstrual health advocacy, inequities in access to menstrual education and services remain stark, especially within school systems. Menstrual health is often treated as a girls-only issue. This gendered silence reinforces stigma, perpetuates myths, and isolates menstruating girls. Furthermore, while many low- and middle-income countries are developing or updating school health and WASH policies, menstrual health is still not always clearly addressed or consistently implemented. These gaps highlight both a global and local failure to integrate MHH into broader reproductive health and gender equity frameworks, a failure that manifests acutely in school settings, including in Zambia. This study investigates the complex interplay of various factors and the cultural perceptions influencing girls\u0026rsquo; menstrual product access and disposal practices. Focusing on understanding and addressing the health disparities within the context of gender equity in reproductive health, significantly impacts reproductive health access among girls. Specifically, the research objectives included (i) examining the relationship of factors affecting menstrual product choices, and sources, (ii) investigating the impact of factors like household income to product access, and (iii) exploring the menstrual waste disposal practices used, to understand the environmental implications and potential human health hazards. This paper sheds light on the cultural beliefs surrounding menstrual health in Lusaka and the implications for accessing reproductive health services. Limited research has explored the intersection of socioeconomic, cultural, and environmental factors in shaping menstrual practices and reproductive healthcare access..\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e \u003cb\u003eStudy population and location\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis was a mixed-methods study of adolescent girls in peri-urban Lusaka City. The targeted population was menstruating adolescent schoolgirls between 10\u0026ndash;19 years old. The inclusion criteria was participants who had reached menarche (experienced their first menstruation) and were less than 19 years old. Based on the Government school's management recommendation, we targeted one class each from the 5th to 9th grade. The school was located in one of the densely populated peri-urban areas, near the central business centre, and is attended by girls from several other peri-urban communities.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuantitative Data\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA cross-sectional design was used to collect socio-demographic data, product preferences and disposal practices of menstrual management. Purposive sampling was used to select menstruators and lower and upper primary participants from the school who met the survey requirements. 400 participants were surveyed, and only 266 provided sufficient data to facilitate analysis. A questionnaire survey was created after an extensive literature review on socio-demographics, socio-economic status, product choice, and menstrual waste disposal practices. Descriptive statistics and further analysis were conducted to interpret the data. Age was divided into two groups based on median age to reveal differences in trends. Product access were categorised as disposable or reusable, with various disposal methods. Multivariable logistic regression analysis was used to identify the determinants of menstrual product preferences and disposal options while controlling for potential confounders. The stepwise regression technique was used to select the best predictive model.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQualitative Data\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFGDs with 24 menstruating girls from the same school aged 12 to 19, representing various peri-urban communities were included using convenience sampling. The focus groups of 8 girls per group lasted for about 90 minutes and explored girls' experiences with product preference and usage, disposal practices, and cultural beliefs surrounding health access. Thematic analysis was performed using MAXQDA 10, with triangulation with three other researchers reinforcing the findings' reliability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Considerations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki, which ensures the protection, dignity, and rights of all research participants. The Ethics Review Committee of the Faculty of Health Sciences, Hokkaido University (No. 2011-0001) reviewed and approved the study protocols and methods. After a thorough briefing on the study, all participants provided informed consent. For girls under 18, informed assent was obtained from parents or guardians per Zambia\u0026rsquo;s legal age of consent.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe findings are based on quantitative and qualitative data. The quantitative data addresses the factors affecting menstrual product access, menstrual waste disposal, and environmental implications. The qualitative data addresses product access, usage, and health concerns and later reveals Waste Disposal Practices And Access To Disposal Facilities.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Quantitative: Factors Affecting Menstrual Product Access\u003c/h2\u003e \u003cp\u003eThe median age was 15.0 years (Inter-Quartile Range\u0026thinsp;=\u0026thinsp;14\u0026ndash;16 years), with 61% attending junior secondary school, sharing similar language and cultural practices (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of adolescent schoolgirls (n\u0026thinsp;=\u0026thinsp;266)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 years and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181 (68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (32)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at menarche\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 years and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254 (95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5\u0026ndash;7 (Primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 8\u0026ndash;9 (Junior Secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e163 (61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRegion (province) groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Monthly Income*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 to \u003cspan\u003e$\u003c/span\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e100 and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (69)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Head\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e113 (42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGuardian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0. (6)]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*1 Zambian kwacha for \u003cspan\u003e$\u003c/span\u003e0.11 US dollar (Exchange rate on 25/12/2022).\u003c/p\u003e \u003cp\u003eIn this study, menstrual absorbent products refer to sanitary pads and cotton wool, whereas reusable products refer to cloth and washable pads. Out of those surveyed, about 67% of girls aged 15 years and below preferred disposable sanitary products like pads and baby diapers. Most participants (99%) sourced disposable materials from local shops and supermarkets. Chi-square analysis showed an association between absorbent materials and the kind of variables: education level (0.0141) attained, product source (0.0001) used, and waste disposal method (0.041) practised ( Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\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\u003eMenstrual product access and participant characteristics\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMenstrual absorbent material\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisposable (n\u0026thinsp;=\u0026thinsp;227)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReusable (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 years and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151 (66.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (71.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76 (33.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (28.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5\u0026ndash;7 (Primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81 (35.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (56.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0141*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 8\u0026ndash;9 (Secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (64.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (43.59)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnic Region\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (26.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (23.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.534\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e121 (53.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (48.72)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46 (20.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (28.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Income\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44 (19.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (28.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 to \u003cspan\u003e$\u003c/span\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (10.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (12.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e160 (70.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (58.97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Income Source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (23.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (23.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (17.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (12.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95 (41.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (46.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (16.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (17.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProduct Source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-made\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.0001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShop/Supermarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e224 (98.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (66.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWaste Disposal Method\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBurn and bury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (46.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (28.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.041*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePit latrine and flushing toilet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e116 (53.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (71.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSanitary Products Monthly Expense\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e1 dollar and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127 (55.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (48.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than \u003cspan\u003e$\u003c/span\u003e1 dollar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (18.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (10.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (25.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (41.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of changing materials daily\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnce or twice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (47.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (48.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.895\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThree times and more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e119 (52.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (51.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Significant p-value\u003c/p\u003e \u003cp\u003e \u003csup\u003e2\u003c/sup\u003e **1 Zambian kwacha for \u003cspan\u003e$\u003c/span\u003e0.11 US dollar (Exchange rate on 25/12/2022).\u003c/p\u003e \u003cp\u003eFrom the logistic regression analysis, the source of products was a significant predictor of the type of product used after controlling the level of education. The chances of the schoolgirls using disposable products were 34 times higher for commercially sourced than home-made products (Adjusted Odds Ratio/AOR) 33.99; 95% CI: 8.98\u0026ndash;128.56) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). From multivariable logistic regression, eligible independent factors for menstrual choices were education level and product source. The access to material showed an association with participants\u0026rsquo; education and where they sourced their products.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of factors contributing to menstrual product access.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMenstrual product type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisposable (n\u0026thinsp;=\u0026thinsp;227)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReusable (n\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5\u0026ndash;7 (Primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81 (35.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (56.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 8\u0026ndash;9 (Secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (64.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (43.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.96 (0.90\u0026ndash;4.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProduct Source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-made\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShop/Supermarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e224 (98.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.99 (8.98-128.56)\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=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Qualitative: Product Access, Usage And Health Concerns\u003c/h2\u003e \u003cp\u003eFor qualitative data on product access, the following framing question was used to identify themes, sub-themes, and codes on product access: what product(s) do you use and why? The first theme addressed the menstrual product(s) used. The sub-themes included preferences, accessibility, and affordability. The codes included pads with wings and diapers, shops and stores, and expensive and alternative products. The second theme addressed the reason for the product(s) used. The sub-themes were health and safety. The codes were rash, itchiness, fungal infections, menstrual pain, safety concerns and perceived chemicals in diapers when cut into two or three pieces. Themes, sub-themes, and codes are shown below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTh Theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSu Sub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCo Codes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Menstrual product Accessibility and its Impact on Choice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Preferences\u003c/p\u003e \u003cp\u003e\u0026bull; Accessibility\u003c/p\u003e \u003cp\u003e\u0026bull; Affordability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Pads with wings; Diapers\u003c/p\u003e \u003cp\u003e\u0026bull; Shops, stores\u003c/p\u003e \u003cp\u003e\u0026bull; Expensive; alternative product\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.Reason for usage and health concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Rash, itchy, fungal infections, pain\u003c/p\u003e \u003cp\u003e\u0026bull; Safety; chemicals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Menstrual Product Accessibility and its Impact on Access\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost girls preferred disposable materials like pads with wings to securely hold underwear or used baby diapers that were cheaper to buy as a single piece, not the whole pack. However, reasons for accessing particular products included:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I choose disposable napkins for their comfort, especially since they have wings to hold onto the pants and tape to remain attached. The cloth napkins do not have tape on the wings or bottom. I always fear that it will fall off and embarrass me.\u0026rdquo; (13 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Disposable pads are the best options; even if we use diapers sometimes, they are not as good as pads\u0026rdquo; (12 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Normally, one to two sanitary packs are enough. My parents buy for me when buying household goods if I\u0026rsquo;m lucky.\u0026rdquo; (13 years)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, baby diapers were used to drain blood because of their wider surface area and affordability. Girls faced challenges accessing products; participants used reusable materials available at home for reuse or disposal as desired.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I use disposable sanitary napkins or baby diapers and reusable sanitary cloth.\u0026rdquo; (15 years).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I also use some leftover napkins and use washable clothes or ask my sisters or mother if they have any left.\u0026rdquo; (14 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have used diapers before. I do not like them, but my mother forces me to use them. When she doesn\u0026rsquo;t have enough money, I add my savings to buy pads since diapers are easy for others to see that you are menstruating (protrude due to big size) (16 years)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Reason for usage and health concerns\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSome girls cited various health concerns influencing their menstrual product preferences, particularly expressing worries about the quality of available products. Specifically, those using cut diapers as makeshift pads were apprehensive about potential skin reactions and itching due to direct contact with the powdery substances inside. While some girls found diapers to be better, others disagreed. Some health concerns highlighted included\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We use disposable napkins because they are effective. However, they give rash or other vaginal reactions.\u0026rdquo; (15 years).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I am worried about the diapers\u0026rsquo; white particles on my skin (cotton dust after cutting diapers to make several pieces to drain blood)\u0026rdquo; (13 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Ummm, I don\u0026rsquo;t use cotton wool. I find it difficult to use\u0026rdquo; (14 years)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSurprisingly, many girls were unaware that schools offered menstrual materials for students experiencing menstruation. Despite the school providing necessary resources and a supportive environment, this lack of awareness resulted in underutilisation and access to such essential services.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Quantitative: Menstrual Waste Disposal Practices\u003c/h2\u003e \u003cp\u003eDisposal methods included burying, burning, pit latrine or flush toilets, and throwing in a waste bin. For disposal practices, eligible independent factors were household income source and product used. About 69% did not know their household income and came from homes headed (42%) by mothers. The age at menarche (15.0 years) was similar to the median age (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMenstrual waste disposal methods used among schoolgirls.\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWaste disposal practice*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurn and bury (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePit latrine and Flush toilet (n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 years and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e79 (69.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (63.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.291\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (30.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (36.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at menarche\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15 years and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e108 (95.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e138 (96.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (2.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (2.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (1.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5\u0026ndash;7 (Primary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (31.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60 (41.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 8\u0026ndash;9 (Secondary)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77 (68.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83 (58.04)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnic Region (province) groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEastern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (24.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40 (27.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorthern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (49.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76 (53.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWestern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (25.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (18.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Monthly Income**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (70.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (61.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50 to \u003cspan\u003e$\u003c/span\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (29.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (38.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69 (61.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e104 (72.73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Income Source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (15.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (31.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.009***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (18.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (16.08)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (45.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (41.26)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (21.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (11.19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProduct Source\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-made\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (1.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (8.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.021***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShop/Supermarket\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e111 (98.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131 (91.61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMonthly expense on sanitary products\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOne dollar and less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27 (23.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (13.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.123\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than one dollar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (51.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e85 (59.44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (24.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38 (26.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFrequency of changing sanitary towels daily\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnce or twice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57 (50.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64 (44.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.365\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThree times and more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56 (49.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79 (55.24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Multiple responses allowed for waste disposal practice.\u003c/p\u003e \u003cp\u003e \u003csup\u003e2**\u003c/sup\u003eZambian kwacha for \u003cspan\u003e$\u003c/span\u003e0.11 US dollar (Exchange rate on 25/12/2022).\u003c/p\u003e \u003cp\u003e \u003csup\u003e3***\u003c/sup\u003eSignificant factor\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows that most (64%) girls aged 15 years and below disposed of sanitary absorbent materials in pit latrines or flush toilets compared to girls (36%) who were 16 years and above. On the education level, girls (58%) at the secondary education level used latrines and toilets for disposal, and girls (42%) at the primary level. Household income source results showed that 73% of the girls did not know their household income, and mothers were the most cited household income source (41%). Chi-square analysis revealed associations between waste disposal practice and three other variables: household income (0.097), household income source (0.009), and product source (0.021), indicating that the significant independent predictors were the source of household income and the type of product used (AOR\u0026thinsp;=\u0026thinsp;2.29, 95% CI: 1.06\u0026ndash;4.95) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of factors associated with waste disposal practices\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=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" 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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eWaste disposal practice*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBurn and Bury (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePit latrine and Flush toilet (n\u0026thinsp;=\u0026thinsp;143)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold Income Source\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth parents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (15.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (31.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (18.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (16.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.38 (1.05\u0026ndash;5.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51 (45.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59 (41.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.34 (1.19\u0026ndash;4.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (21.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (11.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.18 (1.78\u0026ndash;9.82)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMenstrual Product Used\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReusable products\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (9.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (18.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposable products\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e102 (90.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e116 (81.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.29 (1.06\u0026ndash;4.95)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/span\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Qualitative: Waste Disposal Practices And Access To Disposal Facilities\u003c/h2\u003e \u003cp\u003eThe framing question addressed appropriate disposal methods for qualitative waste disposal and facility access results. The first theme addressed disposal locations. The three sub-themes included rinsing off the blood before disposal, throwing, burying or burning and the waste handling procedures. The three corresponding codes were safety and home, discreet and private, and mistrust and evil. The second theme addressed the reason for the preferred disposal methods used. The three sub-themes included cultural beliefs, the disposal options taught, and ideal practices. The corresponding codes were private and hygiene, knowledge and home, preferred and safe. Themes, sub-themes, and codes are shown below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.Sociocultural Perceptions of menstrual waste disposal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Rinsing off the blood before\u003c/p\u003e \u003cp\u003e\u0026bull; Throw, bury or burn\u003c/p\u003e \u003cp\u003e\u0026bull; Waste handling process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Safety; home\u003c/p\u003e \u003cp\u003e\u0026bull; Discreet; private\u003c/p\u003e \u003cp\u003e\u0026bull; Mistrust; evil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.Preferred disposal methods and their influence on practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Cultural beliefs\u003c/p\u003e \u003cp\u003e\u0026bull; Disposal options taught\u003c/p\u003e \u003cp\u003e\u0026bull; Ideal practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Private, hygiene\u003c/p\u003e \u003cp\u003e\u0026bull; Knowledge; home\u003c/p\u003e \u003cp\u003e\u0026bull; Preferred; safe\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eTheme 3: Sociocultural Perceptions of Menstrual Waste Disposal\u003c/span\u003e \u003c/p\u003e \u003cp\u003eMost schoolgirls did not dispose of waste at school. Instead, waste was wrapped in paper or plastic to be carried and disposed of at home after school. Girls preferred to dispose of used materials at home, fearing that evil people would use their menstrual blood to bewitch them. With such superstitions and beliefs about waste, it isn't easy to implement WASH facilities if girls\u0026rsquo; perceptions and needs are culturally sensitive:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;At school, we carry the used napkins back home wrapped in plastic bags\u0026rdquo; (12 years).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We want a toilet (pit latrine) that we can use to throw pads in.\u0026rdquo; (13 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;A trash bin is not ideal at all. I have never thrown in the school. We do not want bins in the school or public places at all. I can only use the bin at home by hiding the waste under other household waste\u0026rdquo; (14 years).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eTheme 4: Preferred disposal methods and their influence on practices\u003c/span\u003e \u003c/p\u003e \u003cp\u003eGirls found it challenging to manage menstrual waste at school. At home, some girls used a pit latrine, burned materials, or rinsed the blood before throwing the garbage in the trash bins. Others mentioned concerns about whom and how their waste is handled at school. Unsafe and lacked sanitary materials:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As for me, rinsing off blood from the napkins and later throwing them away in the bin is the best option\u0026rdquo; (15 years).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Just throwing away the used napkin in the bins is not ideal or good, especially at school where we do not know how the materials will be handled later\u0026rdquo; (14 years).\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The pit latrine is the best. We also dig a hole in the ground to throw away waste. I do not throw away in the trash as others may get the pads from the trash and use them for evil things\u0026rdquo; (13 years).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAll the girls preferred changing materials at home. Some girls revealed that the school toilets were dirty. Some cited practices included:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I do not change pads from school; I always go home where I feel safe.\u0026rdquo; (13 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;No, I do not change, I wait until I get home\u0026rdquo; (12 years)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Throwing away from home, in a trash bin, is good. Even if they put bins in school, we can\u0026rsquo;t use them\u0026rdquo; (15 years).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Factors Affecting Menstrual Products Access\u003c/h2\u003e \u003cp\u003eThis study focuses on the experiences and practices of menstrual management of Zambian schoolgirls, where girls reached menarche from 13\u0026ndash;15 years old [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. A study conducted in Blantyre, Malawi, surveyed 258 women about their sociodemographic characteristics, menstrual absorbent choices, and disposal practices [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and revealed similar practices to those in the present study. Interestingly, girls' experiences and practices in Bangladesh were similar to Zambia and Malawi [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This suggests that practices on menstrual management of adolescent girls are similar regardless of geographical location and socioeconomic status [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMenstrual product choices are affected by accessibility, affordability, reliability, comfort and convenience. Despite financial challenges, girls commonly used disposable absorbent materials for their comfort and absorbency; alternatively, they used cotton wool, baby diapers, and cloth pads. Most girls want to be comfortable and confident that their chosen product will perform well [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A product\u0026rsquo;s performance measure is the ability to protect girls from leakages and associated embarrassment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A study in Zambia highlighted how school boys, for instance, shame and embarrass girls once they gain knowledge of any of the girls\u0026rsquo; particular menstrual days, and worse off, if any \u0026lsquo;menstrual accident\u0026rsquo; or leaks happens while at school [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Also, girls experience fear and anxiety due to harassment from male peers [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. A study in Zimbabwe showed that product choice and consumption go beyond provision\u0026mdash;external environmental factors such as access to water, soap, sanitary facilities, and sociocultural factors also influence decision-making [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In addition, comprehensive education and accurate knowledge are critical in combating gender bias and stigma [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Therefore, girls must be comfortable with the products used, especially when their male counterparts are present at school. Ultimately, affordability, convenience, durability and socio-cultural factors affect the choices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Factors Impacting Product Access, Usage And Health Concerns\u003c/h2\u003e \u003cp\u003eSchoolgirls' household income impacted their materials, despite their preference for commercial and disposal products due to their ease and suitability. Interestingly, girls also used baby diapers as pads and bought them as a single diaper at about \u003cspan\u003e$\u003c/span\u003e0.11 from local retailers and shops. Diapers were easily accessible as a single piece for unanticipated periods without purchasing an entire pack, as with pads, which proved less costly. Access to affordable materials is among the health disparities among lower-income girls [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Also, diapers provided a larger surface area for girls with heavy menstrual flow. Alas, diapers being bigger pose a more significant threat to sewage systems and the environment if disposed of in toilets [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Girls need to be educated and sensitised about the implications of waste disposal, especially in toilets.\u003c/p\u003e \u003cp\u003eMost girls preferred disposable sanitary products with wings and tape for secure attachment to underwear despite financial challenges in accessing quality products. The economic status was crucial, with some girls opting for reusable materials sourced from home due to constraints [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Few participants in focus groups used cotton wool due to the tendency to soil quickly, tearing off, and lack of secure attachment. Girls\u0026rsquo; sources of materials differed, and access did not translate to affordability. Product choices were influenced by availability, product knowledge, and social expectations [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Girls emphasised that products must be accessible, affordable, culturally acceptable [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and comfortable to support sustainable use and environmental safety. Alternative products like menstrual cups and washable absorbent materials have recently become popular due to their environmental and cost benefits [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A study in Zambia that introduced menstrual cups revealed that cups are not commonplace, are perceived to cause cancer or injury to the reproductive organs, and, in some cases, result in loss of virginity. Interestingly, the study also revealed that participants desired to use cups as an alternative product after product and information access [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. However, menstrual cups may not be culturally appropriate in some regions, where inserting anything into the vagina is taboo for unmarried girls due to concerns and fear about virginity. Misconceptions about cup hymen breakage and sexual dissatisfaction persist [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In some cultures, there are also fears about fertility [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Interestingly, despite these challenges, girls showed interest and a need for more awareness about cups. Cultural beliefs significantly impact menstrual choices [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], along with socio-economic factors, product safety, acceptability, and menstrual knowledge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Menstrual Waste Disposal And Environmental Implications\u003c/h2\u003e \u003cp\u003eThe waste disposal methods included burning, burying, pit latrines, flush toilets and waste bins,. Studies in Malawi show that most menstrual waste is thrown in pit latrines or burned [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These practices threaten the sanitary sewage system, human health, and the environment. Some girls rinsed the blood off before throwing waste in bins, like in Indonesia [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Other girls also stated concerns about whom and how waste is handled if disposed of at school, implying a lack of trust and uncertainty about who and how people other than themselves handle their \u0026lsquo;sacred\u0026rsquo; waste. Participants used several methods while expressing the need to learn more about sustainable methods and the implications of their practices. In Zambia, sustainable solid waste management remains challenging in peri-urban areas due to rapid population growth, unplanned sanitary facilities, and inadequate service provision. Sewage systems were blocked due to waste like pads and diapers. A Lusaka study revealed that most of the solid waste generated in the urban areas was not collected and disposed of at designated sites. Solid waste treatment was conducted at minimal rates and was not sustainable [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, in India, waste was disposed of in toilets without knowing the consequences of blockage [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Waste Disposal Practices And Access To Disposal Facilities\u003c/h2\u003e \u003cp\u003eMost girls preferred pit latrines and were unaware of the environmental issues of sewage blockages or time taken to decompose. Most participants were unaware of the amount of plastic in disposable products [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Cultural myths and taboos surrounding waste are also prevalent, as some girls were not utilising municipal garbage collection services unless materials were hidden or blood washed off beforehand, as observed among schoolgirls in Indonesia [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Culture and religion can influence practices when discreetness with waste handling is encouraged, and it may have adverse effects if inadequate knowledge is lacking. Sociocultural factors significantly influenced product choice and disposal practices. Beliefs and teachings about menstruation influenced these practices. Menstruators need access to private, safe, and convenient disposal options that support sustainable use.\u003c/p\u003e \u003cp\u003eA Zambian study revealed that throwing used menstrual materials in toilets was ideal for fear of others mishandling waste for witchcraft practices that may result in menstruators experiencing stomach pains or infertility [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Similar beliefs about menstrual waste being sacred and fear of evil people were cited in our focus groups. Poor knowledge of best disposal practices linked to cultural beliefs has significant environmental impacts. The school environment itself lacked the necessary facilities to manage menstruation despite the girls\u0026rsquo; desire to utilise them. Therefore, menstrual education, provision of female-friendly toilets with locks on doors, water within stalls, and menstrual disposal options are needed in school WASH infrastructures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Menstrual waste remains a neglected MHH and sanitation value chain issue, impacting users, the sanitation systems and the environment [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The lack of acceptable and culturally sensitive disposal infrastructure, menstrual awareness, and social stigma can contribute to unending improper disposal practices. Personal and sociocultural factors and WASH facilities affect the girls' practices and the environment. Our study builds on previous research to explain materials and waste disposal practices in LMICs [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The available facilities, knowledge, and cultural myths influenced the disposal practices.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStrengths And Limitations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOne limitation of the study is using purposive sampling with a relatively small sample size. While purposive sampling enabled us to target girls with relevant characteristics, it limits the generalizability of findings. Nonetheless, this limitation is offset by several strengths of our study. The sampling allowed us to obtain in-depth and detailed qualitative data, providing rich insights into the phenomena under investigation. Moreover, our study addresses a significant gap in the current literature by focusing on an understudied population or phenomenon, adding valuable new knowledge to the field. Additionally, we employed rigorous methodological practices to ensure the reliability and validity of our data through triangulation.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eOur study investigated factors affecting reproductive healthcare access of menstrual materials, disposal and environmental impacts. Firstly, our analysis reveals that menstrual product access among adolescent schoolgirls is influenced by education level and the sources of materials. Most participants preferred disposable materials for comfort, durability, and convenience. Additionally, some girls used baby diapers as a cost-effective alternative for wider absorbency surface area. Household income was also crucial in determining access to quality absorbent materials. While some households prioritised buying menstrual materials, others did not, resulting in MHH disparities and barriers to accessing required materials to manage menstruation. Cultural beliefs influenced disposal practices. For instance, although the school provided sanitary waste bins, they remained underutilised due to cultural teachings regarding the sacred nature of menstrual waste. Consequently, girls carried their waste home, most discarding waste in pit latrine toilets without considering the environmental impacts. The findings underscore the necessity of providing culturally acceptable and sensitive disposal options and facilities. Such measures are essential to creating MHH-friendly facilities and promoting educational equity and advancement.\u003c/p\u003e \u003cp\u003e \u003cb\u003eNovelty And International Relevance\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study contributes novel perspectives by identifying the sociocultural factors and infrastructural constraints in peri-urban Lusaka to inform context-specific interventions that enhance menstrual equity and strengthen reproductive healthcare service access. In moving toward menstrual equity, it is essential to recognise that cultural beliefs and gender norms profoundly shape how menstruation is experienced and managed. Respecting cultural sensitivities does not mean avoiding the conversation; instead, it means engaging communities in ways that honour their values while protecting health and dignity. Inclusive menstrual education involving accurate knowledge of products and disposal and incorporating both girls and boys in the discourse, paired with context-sensitive infrastructure and policy support, can reduce stigma and foster understanding.\u003c/p\u003e"},{"header":"6. Future Research and Policy Implications","content":"\u003cp\u003eThese findings also highlight deeper systemic inequities within school-based reproductive health education. While some schools provide menstrual products, the lack of awareness among girls reflects a communication gap. More critically, the exclusion of boys from menstrual health education perpetuates stigma and reinforces harmful gender norms. Globally, MHH is often framed as a private, female concern, leaving boys uneducated and girls unsupported. This unequal distribution of information contributes to reproductive health inequities, as girls bear the burden of secrecy and shame. In Zambia, like in many settings, school health policies lack explicit guidance on integrating MHH into comprehensive reproductive health education for all students. Addressing this silence through inclusive, gender-transformative education could help dismantle stigma and promote shared responsibility in menstrual health.\u003c/p\u003e \u003cp\u003eImportantly, the exclusion of boys from menstrual health education contributes to a broader inequity in reproductive health knowledge. While boys may not require menstrual products, their lack of accurate information perpetuates teasing, misunderstanding, and a culture of silence that directly affects girls\u0026rsquo; dignity and safety at school. This creates an unequal emotional and social burden for menstruating students, placing the responsibility of discretion, coping, and shame solely on girls. Promoting inclusive menstrual health education\u0026mdash;without breaching cultural sensitivities\u0026mdash;can help cultivate mutual respect, reduce stigma, and shift school environments toward greater gender equity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of Interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have nothing to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur research activities were supported by: (i) “The Sanitation Value Chain: Designing Sanitation Systems as Eco-Community Value System” Project, Research Institute for Humanity and Nature (RIHN, Project No.14200107), and (ii) No. 22489817).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJS wrote the main manuscript, and SN edited and revised it. TY provided the methods, supervision and proofreading. YHK helped in the analysis and re-arranging of materials. All authors revised the manuscript and authorised the final draft.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe want to thank all study participants, school management in Zambia, the Sanitation Value Chain (SVC), colleagues from the Africa-Japan Collaborative Research (AJ-CORE: COCO WASH) project, Hokkaido University, my colleague Jessy Ruth Z'gambo, my husband and mentor Mwape Chitupa, my children, friends and family.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLuchese CL, Engel JB, Tessaro IC. Disposable, reusable and biodegradable hygiene products. Antimicrobial Textiles from Natural Resources, Elsevier; 2021. pp. 421\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTu J-C, Lo T-Y, Lai Y-T. Women\u0026rsquo;s Cognition and Attitude with Eco-Friendly Menstrual Products by Consumer Lifestyle. Int J Environ Res Public Health. 2021;18:5534.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips-Howard PA, Caruso B, Torondel B, et al. Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities. Glob Health Action. 2016;9:33032.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnbesu EW, Asgedom DK. Menstrual hygiene practice and associated factors among adolescent girls in sub-Saharan Africa: a systematic review and meta-analysis. BMC Public Health 2023;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSambo J, Nyambe S, Yamauchi T. A qualitative study on menstrual health and hygiene management among adolescent schoolgirls in peri-urban Lusaka. Zambia J Water Sanitation Hygiene Dev. 2024;14:15\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePadmanabhanunni A, Fennie T. The menstruation experience: Attitude dimensions among South African students. J Psychol Afr. 2017;27:54\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlexander K, Oduor C, Nyothach E, et al. Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls? Water (Basel). 2014;6:1453\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAtari DO, Tariquzzaman SK, Nancy A. Knowledge and Perceptions on Menstrual Hygiene Management Among School-Going Adolescent Girls in South Sudan. J Adolesc Res 2021:074355842110432.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur R, Kaur K, Kaur R. Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries. J Environ Public Health. 2018;2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSai A, Furqan RAL, Ushijima K, et al. Physical and Mental Health of Sanitation Workers in an Urban Slum of Indonesia: Personal Hygiene and the Construction of Self-Esteem in. Waste-Handling. 2021;5:26\u0026ndash;027.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra-Mouli V, Patel SV. Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries. Reprod Health 2017;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSambo J, Muchindu M, Nyambe S, et al. Sustainable Solid Waste Management: An Assessment of Solid Waste Treatment in Lusaka, Zambia. Sanitation Value Chain. 2020;4:39\u0026ndash;050.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilmouth R, Muller N, Truyens C et al. Interactions between menstrual hygiene management and sanitation systems: Landscape analysis of menstrual hygiene products and a waste-loading model. 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLahme AM, Stern R, Cooper D. Factors impacting on menstrual hygiene and their implications for health promotion. Glob Health Promot. 2018;25:54\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoxburgh H, Magombo C, Kaliwo T, et al. Blood flows: mapping journeys of menstrual waste in Blantyre, Malawi. Cities Health. 2022;6:738\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConnolly S, Sommer M. Cambodian girls\u0026rsquo; recommendations for facilitating menstrual hygiene management in school. J Water Sanitation Hygiene Dev. 2013;3:612\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa MAT, Alam MdZ. Menstrual hygiene management practice among adolescent girls: an urban\u0026ndash;rural comparative study in Rajshahi division, Bangladesh. BMC Womens Health. 2022;22:86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeberdy E, Jones A, Green D. A Study into Public Awareness of the Environmental Impact of Menstrual Products and Product Choice. Sustainability. 2019;11:473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSommer M, Torondel B, Hennegan J et al. How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals. Glob Health Action 2021;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavidson A. Narratives of Menstrual Product Consumption. Bull Sci Technol Soc. 2012;32:56\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChinyama J, Chipungu J, Rudd C, et al. Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences and challenges faced by schoolgirls. BMC Public Health. 2019;19:16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTembo M, Renju J, Weiss HA, et al. Menstrual product choice and uptake among young women in Zimbabwe: a pilot study. Pilot Feasibility Stud. 2020;6:182.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZablock K, Fei YF. Young Men\u0026rsquo;s Attitudes and Understanding of Menstruation. J Adolesc Health. 2024;74:782\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavies S, Darien K, Wood S, et al. 79. A Multimodal Approach to Understanding the Barriers and Facilitators to Adolescent Menstrual Health Equity. J Adolesc Health. 2022;70:S41\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur R, Kaur K, Kaur R. Menstrual Hygiene, Management, and Waste Disposal: Practices and Challenges Faced by Girls/Women of Developing Countries. J Environ Public Health. 2018;2018:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGondwe M, Simuyaba M, Phiri M, et al. Acceptability of and experiences with menstrual hygiene cups among adolescent girls and young women aged 15\u0026ndash;24 in two communities in Lusaka, Zambia: an exploratory study nested in the Yathu Yathu trial. Reprod Health. 2025;22:20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKambala C, Chinangwa A, Chipeta E, et al. Acceptability of menstrual products interventions for menstrual hygiene management among women and girls in Malawi. Reprod Health. 2020;17:185.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePokhrel D, Bhattarai S, Emg\u0026aring;rd M, et al. Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study. Reprod Health. 2021;18:20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSato K, Hamidah U, Ikemi M, et al. Menstruation and Menstrual Hygiene Management: A Case Study of Adult Females in an Urban Slum of Indonesia. Sanitation Value Chain. 2021;5:83\u0026ndash;097.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElledge M, Muralidharan A, Parker A, et al. Menstrual Hygiene Management and Waste Disposal in Low and Middle Income Countries\u0026mdash;A Review of the Literature. Int J Environ Res Public Health. 2018;15:2562.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescents, Disposal Practices, Reproductive Health, Menstrual Health, Menstrual Product Access, Lusaka-Zambia","lastPublishedDoi":"10.21203/rs.3.rs-6346873/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6346873/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAccess to reproductive health services is crucial for the empowerment and well-being of women and girls in low-, middle-, or high-income countries, particularly in Menstrual Health and Hygiene Management. Despite global progress in menstrual health advocacy, disparities in menstrual product access, usage and disposal persist, especially in low-resource settings. Adolescent girls in the peri-urban Lusaka, Zambia, face significant sanitary product affordability, access, and disposal infrastructure challenges. Additionally, cultural perceptions and societal stigmas further shape menstrual health experiences, influencing both product access and disposal behaviors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Employing a mixed-methods cross-sectional approach, menstruators from one Government school in Peri-urban Lusaka (n\u0026thinsp;=\u0026thinsp;266) aged 12\u0026ndash;19 were surveyed alongside participants (n\u0026thinsp;=\u0026thinsp;24) from different grades (5\u0026ndash;9), purposively sampled from various peri-urban communities, and in focus group discussions, contributing to an essential discourse on health service access. Data were analysed using JMP Pro and MAXQDA 10 after triangulation with other researchers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eQuantitative findings revealed a marked preference for disposable menstrual products (85%), with users reporting higher levels of comfort and convenience. Supermarkets and retailers accounted for 94% of the product supply, while others sourced available homemade materials. Menstrual. In contrast, reusable products were utilised primarily by households with lower economic means, where accessibility and cost were significant factors. Statistical analysis indicated a strong correlation between education level and preferred product type, highlighting that increased awareness leads to a stronger inclination towards sustainable options. Qualitative insights from focus groups underscored the influence of cultural beliefs on menstrual management. Participants often transported waste home for discreet disposal, reflecting a cultural understanding of managing waste while identifying inadequate disposal facilities outside the house. Thematic analysis identified key cultural narratives that prioritise discretion and comfort but overlook environmental and health considerations, revealing gaps in knowledge that can hinder adequate reproductive health access.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOur research reveals significant disparities in the availability and acceptance of menstrual products, highlighting the roles of social stigma, educational opportunities, and environmental considerations. Enhancing access to culturally relevant menstrual health resources can significantly advance gender equity in reproductive health access. Findings suggest critical avenues for culturally sensitive interventions that provide access to appropriate menstrual products and foster educational programs about environmental impacts and health implications. By addressing these cultural dynamics and enhancing the availability of hygiene facilities, we can significantly improve girls\u0026rsquo; experiences and promote gender equity in reproductive health. Interventions in reproductive health must include service delivery and more access to quality products for vulnerable populations like adolescent girls.\u003c/p\u003e","manuscriptTitle":"Gender Equity in Menstrual Health: Challenges in Product Access and Disposal Among Adolescent Girls in Lusaka, Zambia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-28 07:49:33","doi":"10.21203/rs.3.rs-6346873/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-19T05:06:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T16:23:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134068904297343741896595782978319465559","date":"2025-06-25T09:43:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219052113653193555281288905106114532902","date":"2025-06-23T15:10:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"256570072641912724890263975683939160766","date":"2025-05-02T09:05:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"179317064517241233045070890900177823846","date":"2025-04-25T19:15:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40118119473950582521847050244265717379","date":"2025-04-24T13:35:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-24T13:03:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-04T08:22:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-02T01:20:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Reproductive Health","date":"2025-03-31T17:01:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"reproductive-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"reph","sideBox":"Learn more about [Reproductive Health](http://reproductive-health-journal.biomedcentral.com)","snPcode":"12978","submissionUrl":"https://submission.nature.com/new-submission/12978/3","title":"Reproductive Health","twitterHandle":"@Reprod_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c11a6c68-9bae-4e1d-bec1-d3919da17e87","owner":[],"postedDate":"April 28th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-19T05:06:05+00:00","index":33,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-28T07:49:33+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-28 07:49:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6346873","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6346873","identity":"rs-6346873","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}