Menstrual inequity: the ‘stain’ on participation and democracy in South Africa

Menstrual inequity: the ‘stain’ on participation and democracy in South Africa | 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 Menstrual inequity: the ‘stain’ on participation and democracy in South Africa Sinazo Nomsenge This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5432759/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Healthy experiences of menstruation require access to material and nonmaterial resources including sanitation facilities, privacy and comfort infrastructure, hygiene and pain management products as well as accurate and empowering menstrual education. These resources remain inaccessible for many women and adolescents thereby compromising their participation in various aspects of their socioeconomic advancement including schooling, work, and personal development. For adolescents, inadequate access to essential menstrual resources compromises schooling experiences with research suggesting that in addition to many adolescents missing school during menstruation, the quality of their social and educational participation is significantly impeded by the lack of access to essential resources. Beyond this, limited access to critical resources and infrastructure interferes with women’s work and socioeconomic engagements in ways that compel many to employ menstrual concealment practices that compromise their health, comfort, safety, and ultimately, their equitable participation in social and economic activity. Moreover, stigma and secrecy surrounding menstruation limit open engagements about menstrual needs and challenges thereby making various aspects of society inherently inequitable and incapable of fostering democratic participation. This paper draws on qualitative phenomenological research conducted with 15 women living in uMlazi and Inanda in KwaZulu-Natal, South Africa. In-depth interviews were used to explore participants’ experiences and perceptions on how menstrual inequity influences patterns of socio-economic, educational, and developmental participation among adolescents and women. From data collected, the paper suggests that inadequate access to essential menstrual resources shapes inequitable patterns of participation in schooling, work, social and developmental activity. Menstruation Participation Democracy Menstrual Equity Sociology of Health 1. Introduction Menstruation is a characteristic of reproductive development that is experienced by 1.8 billion individuals with experience thereof being shaped by individuals’ access to essential material and nonmaterial resources, often referred to as hardware and software menstrual resources (Bobel, et al., 2020 ). Foremost among these is access to suitable Menstrual Hygiene Products (MHPs), related disposal and/or laundering facilities as well as pain and comfort management resources. Alongside this, menstruating individuals require sustained access to water, sanitation and hygiene resources, accurate and empowering menstrual education as well as supportive environments that enable safe and comfortable menstrual management (Sumpter & Torondel, 2013 ; Hennegan, et al., 2021 ). Unfortunately, these resources remain inaccessible for many. Research conducted over the past two decades especially demonstrates how inadequate access to menstrual resources compromises individuals’ physical and psychological health thereby significantly impeding on their ability to engage equitably and productively in public life (Macleod, du Toit, Paphitis, & Kelland, 2020 ; Bloem, 2021 ; Fennie, Molestane, & Padmanabhununni, 2021 ). For many adolescents, the lack of access to menstrual resources disrupts attendance and participation in schooling with studies suggesting that even among those who are able to attend school during menstruation, participation in educational and school-based social and physical activity is significantly disrupted (Chinyama, et al., 2019 ; Crankshaw, Staruss, & Gumede, 2020 ). In addition to having limited access to suitable or preferred menstrual and pain management products, water and sanitation facilities at many schools remain unsuitable for safe, healthy and comfortable menstrual management. Additionally, broader sociocultural belief systems constrain the circulation of accurate and empowering information about menstruation with secrecy and stigma characterising the experiences of many (Fennie, Molestane, & Padmanabhununni, 2021 ; Patel, et al., 2023 ). In and beyond schooling environments, menstruation continues to be shrouded in secrecy and stigma with material shortcomings compounding the complexities with which adolescents and adults must contend in managing their menstruation. Studies from various contexts suggest for example, that compliance to socio-cultural prescripts of menstrual etiquette compels adult women to manage their menstruation with secrecy often to the detriment of their health, safety and comfort (Hennegan, et al., 2020 ). Additionally, many women in resource-deprived communities cope with inadequate access to menstrual resources by making use of alternative materials to absorb menstrual blood and by employing various menstrual concealment practices that disrupt their comfort and engagement in personal, public, educational, social and economic activity (Bapat & Agarwal, 2003 ). Research has also found that places of employment are often ill-equipped to accommodate the menstrual needs of individuals thereby compelling many to employ unhealthy and uncomfortable coping mechanisms that disrupt work attendance and participation (Sommer, Chandratna, Cavill, Mahon, & Phillips-Howad, 2016 ; Hennegan, et al., 2020 ). Within this field of research, studies have therefore not only identified the material and nonmaterial resources needed for healthy experiences of menstruation, but they have also uncovered the dire consequences of inadequate access to these resources on individuals’ health, safety, comfort and overall wellbeing. Moreover, scholars have inadvertently alluded to the implications of inadequate access to menstrual resources on academic, economic and socio-developmental participation. This paper seeks to extend this line of inquiry by consolidating and outlining the consequences of menstrual inequity on the patterns of participation in schooling, work, social and developmental activity among adolescents and adult women living in Inanda and uMlazi in South Africa’s KwaZulu-Natal Province. The paper goes on to opine on the implications of these patterns of participation on democracy within these institutions and in society at large. By so doing, the paper gestures towards the need for broader interrogations of menstrual inequity that accompany the localised explorations of menstrual experiences that have largely characterised the field thus far. 1.1 Problem Statement Somerville ( 2011 : 417) recounts democracy to be largely understood as “an ideal or principle, namely that of popular equality”. Crawford, et al., ( 2020 : 344) go on to suggest that given that menstruation is uniquely experienced by a subset of the global population, “only an equity approach can ensure that menstruators have safe and affordable access to the menstrual hygiene products they need in order to be full participants in society”. And indeed, menstrual research has largely sought to expound on the needs of individuals who menstruate with increased focus on the intersection of needs and vulnerabilities incurred by individuals who come from low socioeconomic settings. Research has especially honed in on the consequences of the lack of access to menstrual resources among adolescents and working women in Low to Middle Income Countries (LMICs) (Bobel, et al., 2020 ). These consequences include interrupted school and work participation among adolescents and women respectively. While these have been considered in isolation from one another, taken together, research has demonstrated how disrupted academic and socioeconomic participation both flow from the same societal trends of inadequete access to essential menstrual resources. While doing so, studies have however, failed to consider the broader societal implications of these intergenerational complexities on patterns of participation and subsequently, the realisation of democracy in institutions and society as a whole. This paper contends with this gap by exploring adolescents and women’s participation in academic, social and economic activities and discussing the implications thereof on the realisation of equitable participation and democracy. 1.2 Research Questions This study explores how menstrual experiences shape patterns of academic, economic and sociodevelopmental participation among adolescents and women in KwaZulu-Natal. Adolescent’s and women’s access to essential menstrual resources is explored along with the ways in which their patterns of access to these resources shape their menstrual experiences and subsequently, their participation in public life. As such, the study is guided by the following core research questions: In what ways are menstrual experiences influenced by patterns of access to menstrual resources? How does access to menstrual resources influence individuals participation in public life? 2. Methodology 2.1 Research Paradigm This study was informed by an interpretivist research paradigm which, according to Alharahseh & Pius ( 2020 ) concerns itself with the subjective realities of individuals, the meanings that individuals construct about these realities and how they are experienced and interpreted. Unlike positivism which seeks to establish universal explications of reality, interpretivist research delves into the variety of encounters with reality and the interpretations thereof (Kivunja & Kuyini, 2017 ). Furthermore, Pervin & Mokhtar ( 2022 ) suggest that interpretivist research is founded on the belief of social reality being informed by various contexts and individuals’ subjective experiences of these contexts. Informed by the interpretivist paradigm, this study sought to provide detailed insight into individuals experiences, perceptions and ideas. The study was also aimed at detailing individuals’ varied lived experiences and exploring the interpretations, meanings and ideas used to make sense of them. By so doing the study sought to draw out details about individuals’ social contexts and to locate within these contexts, their menstrual experiences and implications thereof on their academic, economic and sociodevelopmental participation. 2.2 Research Design The interpretivist paradigm employed for this study along with the research questions, informed the adoption of a phenomenological research design. Asserting it as both a philosophy and method of inquiry, Qutoshi, ( 2018 ) proposes phenomenology to be an approach suitable for developing a broader and deeper understanding of reality. Citing Gearing ( 2004 ), Qutoshi ( 2018 : 217–218) goes on to suggest that phenomenology facilitates the careful examination of a phenomenon as it is experienced and perceived by individuals and does so through in-depth explorations of the ideas and interpretations used by individuals to make sense of said phenomenon. This approach was adopted for this study as it aligns with its core research questions and was deemed a suitable approach for responding to the core aims thereof. In particular, the approach facilitated a detailed exploration of the phenomena that are foundational to this study namely, menstrual inequity and participation. The approach was also a salient framework to be used to facilitate a detailed inquiry into the experiences and interpretations of said phenomena. 2.3 Population and Sample This study was conducted with members of township communities, uMlazi and Inanda in South Africa’s KwaZulu-Natal Province. Adult women aged 25years and above were purposively sampled to participate in the study with the final participant pool consisting of 15 women aged between 26–52years. As recommended by Campbell, et al., ( 2020 ) a purposive sampling technique is suitable for the: “matching of the sample to the aims and objectives of the research, thus improving the rigour of the study and trustworthiness of the data and results”. As such, this study sought to sample individuals who would be better placed to provide data related to the phenomena under investigation. This is to say that this sampling technique was chosen with the aim of sampling individuals who may be better able to share and recount on personal experiences and perceptions related to the subject matter (Thomas, 2022 ). In this case, women who have personal experiences with menstruation from within the chosen research sites were purposively sampled to participate in the study. 2.4 Data Collection Tools/instruments Prior to the collection of data, the study was presented to prospective participants with information sheets being distributed in order to allow individuals to carefully consider their decision to participate in the study and the implications thereof. Individuals interested in participating were required to read, understand and sign an informed consent form which provided details about the study, the risks and benefits of participating as well as the voluntary nature thereof. Interested individuals were also advised of their freedom to withdraw from the study at any time and without any consequences to their access to services and/or resources. After demonstrating an understanding of the study and consenting to participate, individual interviews were then scheduled and conducted in participants’ most preferred language. With consent from participants, interviews were audio recorded after which they were transcribed verbatim and translated into English where necessary. Semi-structure interviews were the chosen mode of interviewing for this study as, according to Elhami & Khoshnevisan ( 2022 ), this mode of interviewing allows for a detailed exploration that is guided by topic areas derived from the research questions and reviewed literature. The flexible yet adaptable nature of semi-structured interviews is, according to Ruslin, et al., ( 2022 ) ideal for qualitative research as it allows the interviewers to determine the depth of engagements with participants while also providing sufficient adaptability to the unpredictable nature of participant responses. As such, this mode of interviewing was considered ideal for this study in order to explore themes already established in reviewed literature but to also explore emerging themes, ideas and experiences within the chosen research context and among the sampled participants. This mode of interviewing was also guided by the phenomenological paradigm which informed the use of open-ended questions to explore the areas of interest derived from the research questions and reviewed literature (Høffding & Martiny, 2016 ). This paradigm underpinned the implementation of this semi-structured interview method in order to explore participants’ perceptions, ideas, memories, experiences and recollections. 2.5 Data Analysis Thematic analysis is defined by Dawadi ( 2020 : 62) as a “qualitative research [analysis] method that researchers use to systematically organise and analyse complex data sets”. This analysis method “ involves the identification of themes through careful reading and re-reading of the trascribed data” (ibid). As recommended by Braun & Clarke ( 2006 ), this mode of analysis can be utilised inductively and deductively which indicates that pre-established themes (or codes) can be used to guide the analysis of a data set and data can be also analysed through codes that are obtained from patterns and themes emerging from the data set. In light of this, data collected for this study made use of both inductive and deductive thematic analysis in order to guide the analysis of data with the use of pre-established themes while also allowing the data to inform the establishment of themes. This analysis process was implemented with the use of the qualitative data analysis software, Atlas.ti. 2.6 Ethical Consideration Ethical approval to conduct this study was obtained from the University of KwaZulu-Natal’s Humanities and Social Sciences Research Ethics Committee (Protocol HSSREC/00006993/2024). With permission from local leaders, the study was presented in-person to prospective participants and interested individuals were invited to complete and sign consent forms prior to participating in interviews. After obtaining verbal and written consent to be interviewed, interviews were scheduled to align with participant’s availability. The collection and analysis of In order to preserve participant’s anonymity, no personal information was recorded for the study and pseudonyms are used when reference is made to participants’ views and responses. 3. Presentation of Results and Discussion Data collected for this study sought to explore patterns of access to essential menstrual resources in order to illustrate the trends of menstrual inequity within the chosen research sites. The study was also aimed at exploring how patterns of access to menstrual resources shape women’s experiences of menstruation and ultimately, their patterns of participation in academic, economic and socio-developmental activity. With the view of addressing the research questions of this study, data collection was centred on literature-based themes and sub-themes as follows: Access to Essential Menstrual Resources Menstrual Hygiene Products Water, Sanitation & Hygiene Facilities Pain Management Education and Support Menstrual Experiences and Participation in Public Life Additionally, the following sub-themes emerged from data collected and were used to further organise and analyse the data set: Social Participation Academic Participation Economic & Developmental Activity 3.1 Essential Menstrual Resources Women’s menstrual experiences are significantly impacted by their access to essential material and non-material resources. As does literature reviewed, data collected for this study identifies several material resources that are essential for the safe and comfortable management of menstruation. For study participants, access to sanitary pads and pain management products is deemed to be especially integral for sustaining comfortable menstrual experiences. For some, access to these resources is consistent while for a greater majority, access remains uncertain. With disposable sanitary pads being the most preferred menstrual hygiene product for all participants sampled, affordability was identified as the primary factor determining one’s ability to comfortably manage their menstruation with broader socioeconomic status being the underlying context of one’s affordability. Likewise, access to preferred pain management products is identified as paramount to one’s menstrual management although remaining uncertain for many. Affirming this, several participants recall instances of being unable to access sanitary and pain management products during menstruation with Bongi recalling a recent personal experience by saying: “The shop was very close, we just did not have money; pads were also cheap because you were able to buy one pad for R2 1 , but I did not even have that R2” . Similar experiences and observations are shared by several other participants as follows: “If you go to the shops you will find that only some women buy them. I do not even know how much they cost because I myself, cannot afford them.” [Lilitha] “My neighbour’s children get their pads from me because they cannot afford them; they cannot even afford to buy food so I help them out with pads because they are a necessity for a woman.” [Zama] “If I don’t have money for painkillers, I will have to endure until I’m fine; even my daughter, she has to endure until the end of her period” [Thobeka] Participants’ experiences and recollections thereof illustrate how uncertain access to essential menstrual resources significantly shapes menstrual experiences for better or worse. Additionally, what data collected for this study also demonstrates is the intergenerational nature of experiences of menstrual inequity with adolescents and adults being significantly impacted in varied ways. Reflecting on this, participants in this study also shared personal experiences and observations of how they and others navigate and cope with the constraints that complicate their menstrual management. In the main, making use of alternative materials to manage menstrual blood and asking neighbours and friends were the primary coping mechanisms shared by participants with Zama highlighting the indignity of the latter by saying: “ I shouldn’t have to go around begging people for pads” . To this, other participants elaborate on their own experiences and observations as follows: “My daughter used to attend a local school where they did not get pads, so if I did not have money, I asked other girls who got pads from their schools” [Lilitha] “There are people who struggle to access menstrual products, for instance my friend…sometimes she gets her periods when she does not have pads and I don’t have them either. It gets difficult because she ends up going to people’s houses to ask for them. Imagine asking for pads when you are an adult woman?! That’s not right.” [Mandlakazi] “In tough times, when you don’t have anything else to use…you rush to get the newspaper, you soften it and put it on. Sometimes we use cloths while we are trying to make means to buy pads” [Bomi] “Sometimes people don’t say that they can’t afford pads because they fear that people will laugh at them for using cloths, towels or tissues because they cannot afford a pad.” [Zingce] “I have a friend who sometimes goes to the local tuckshops and asks to get pads on credit. Others end up getting into prostitution to try and make a living; you’ll hear them saying, ‘I can’t even buy myself pads’” [Nonkuleko] These and other sentiments shared by participants in this study highlight not only the dire state of menstrual inequity but also the indignity thereof. Moreover, in the case of uncertain access to effective and preferred pain management products, endurance along with several home remedies were shared as coping mechanisms employed by participants. While some indicated that they often endure the pain until the end of their period ( n = 6) others shared home remedies that they make use of including either drinking warm water with lemon juice, plain hot water or strong black coffee, chewing on cloves or using a hot water bottle or heating pad. While the effectiveness of these home remedies was confirmed by only a few participants ( n = 3), access to effective diagnosis of cases of excessive bleeding and extreme menstrual cramps was confirmed by none, with two participants noting: “I went to the clinic to ask them if this amount of bleeding is normal, they just gave me pain killers that didn’t even help with the cramps or the bleeding” [Sinakokonke] Cramps and over-bleeding are a struggle for many of us; you can go to the clinic to get help and you’ll have to wait in a long line all day just to get Pain Block which does not help with those extreme pains.” [Lilitha] In addition to these complexities encountered as a result of insufficient access to preferred sanitary and pain management products, women sampled for this study also convey experiences related to infrastructural shortcomings in their homes and communities that complicate their menstrual management as well as their overall health and wellbeing. In particular, inadequate access to water, sanitation and hygiene facilities obstructs the proper disposal of sanitary products as well as women’s privacy, safety and their overall hygiene management needs during and beyond menstruation. For some participants ( n = 9), consistent access to clean water remains an elusive ideal the absence of which significantly impedes on basic menstrual and general health management. Additionally, the lack of disposal amenities, soap and sanitary infrastructure that enables privacy, comfort and safety underscores uncomfortable, unhealthy and unsafe menstrual management experiences. “Every day around 7pm our water gets cut until the next morning around 5am. So, you can’t flush the toilet or change pads… EVERYDAY [participant emphasis]. It’s been over 20 years now…Imagine if you have an accident in the middle of the night? that’s why we have to keep bottles to store water.” [Mbalenhle] “In the informal settlements, even the showers are for everyone. Even if they were separated, still they will use the same toilets…the rape will be high in those communities because those toilets usually don’t have proper locks or lighting and girls also use them. A parent can say ‘go to the toilet, it’s okay because I’m close-by in the house’. Yet, they don’t know what happens to the child in the toilet.” [Zama] “In some places, they share bathrooms; so imagine if a woman who is menstruating has bled a lot and they want to shower, they go to the container and find a queue. You now have to wait uncomfortably, imagine that.” [Zinzi] “Sharing this toilet with other people is a challenge because while I’m inside needing my privacy, the other person will not understand that…Imagine being in the toilet changing a pad, and then a man comes in, maybe if the door does not close properly for some reason…You will feel that discomfort because now there is a man in the toilet with you.” [Mandlakazi] “Here in the shacks, we all sleep in one space, there are no rooms so I have to make sure I bath quickly…so I have to shout and tell them [family members] I am still busy so that they won’t come in. So, there is no privacy really, the children are up and down, you can’t have private space to do your things.” [Zodwa] “I think there should be a limit to how many people can use a toilet; for instance, if there are 3 toilets, 10 people could be allowed to use one toilet and each household can be given a key for their toilet because it’s so easy to get infections if a lot of people use one toilet, especially for us, women.” [Nonhle] Participant responses and data collected for this study as a whole demonstrates the network of socioeconomic inequities that intersect at and inform women’s menstrual management experiences (Truyens, Wilmouth, Buckley, Turnberg, & Daniell, 2013 ). Socioeconomic status which shapes women’s access to financial resources constrains the ability to secure essential sanitary and pain management products while broader housing, water and sanitation infrastructure impedes on the ability to comfortably and safely manage menstrual health and hygiene. In the absence of these essential resources, women employ less-than-ideal coping mechanisms and are at the mercy of gender-non-responsive sanitation facilities that compromise their menstrual and broader wellbeing. 3.2 Menstrual inequity and participation Given that menstrual experiences do not occur in a vacuum, this study also sought to explore how menstrual inequity ‘bleeds’ into various aspects of adolescents’ and women’s lives and particularly how it shapes individuals’ participation in various public activities. Data collected for this study, in addition to highlighting that individuals’ menstrual experiences are located with broader societal trends of inequity and socioeconomic scarcity, also points to the disruptions waged against adolescents’ and women’s participation in public life. Among adolescents, findings from this study affirm previous research propositions of the negative impact of menstrual inequity not only on patterns of school attendance but also on the quality of participation therein. “It is so sad to see a child getting their period and falling behind on their studies because they have cramps…The government should make sure that every child can easily get pain medication because a lot of school girls experience cramps.” [Zinzi] “When I started my period, I did go to school but on day one of my period, I was always told to go back home because I bled so much that the blood dripped down my legs…it came to a point where I knew not to go to school during my menstruation because I was going to get sick.” [Mbalenhle] “I wasn’t comfortable even when I was at school…I was always nervous, wondering if I would be fine when I stand up, especially when I didn’t have another pad to change.” [Mandlakazi] “You sometimes find a child running to you in the morning asking to borrow a pad before they go to school. Now, imagine if they only have that one pad? they’ll be worried and uncomfortable at school all day…it’ll affect them” [Phumeza] Adolescents’ uncertain access to essential menstrual and pain management products stems from broader socioeconomic constraints that ‘bleed’ into their participation in schooling (Chinyama, et al., 2019 ; Crankshaw, Staruss, & Gumede, 2020 ; Bloem, 2021 ). For some adolescents, this results in sporadically or consistently missing schooling days while for many others, it culminates in compromised participation therein (Fennie, Molestane, & Padmanabhununni, 2021 ). Likewise, adult women’s participation in employment as well as social and economic activity is significantly impacted by these same patterns of menstrual inequity (Hennegan, et al., 2020 ). Data collected for this study indicates that many women self-isolate during menstruation largely as a result of inadequate access essential and preferred menstrual resources. For some women, especially those who experience heavy menstrual flows, the absence of preferred sanitary products elicits a fear of staining one’s clothes and by extension, having their menstruation being unduly disclosed to others. This, as described by study participants is a “shame” for which self-isolation provides both protection and a space to freely attend to any unpredictable menstruation-related occurrences. “I usually just stay at home when I’m menstruating. I only go out if I really have to. I don’t want to go anywhere even if there is an event happening somewhere in my community, I don’t go because menstruation is so unpredictable and the pads that I can afford may let me down at the wrong time and at least at home, I can change it or take a bath quickly.” Additionally, pain and discomfort affirm participants’ preferences of staying at home during menstruation with home being a place wherein one can privately tender to their physical and emotional needs while also coping with material inadequacies, privately. “I stay at home as much as I can during my period; it’s more comfortable and it saves me money. When I’m at home, I use a cloth that I wash and reuse later, but when I go out, I have to have pads that I change and throw away after a few hours” As suggested by study participants therefore, menstrual experiences and coping strategies employed in the face of inadequate resources shape the nature and quality of one’s engagements public life. This includes employment, church, social life and community work. Within these spaces, women must navigate menstrual pain and discomfort, alongside inadequate menstrual and pain management products. Several participants ( n = 9) recount common personal or observed instances of engagement in work, church, social or other public activity being disrupted by negative menstruation-related experiences. Many of these experiences include elements of limited access to preferred menstrual or pain management products as well as inadequate sanitation facilities. “A lot of people don’t have jobs but they still they need pads…they may also be in serious pain and not have money to buy medication. And now they have to be up and down looking for work but they must also buy pads and medication?” [Lilitha] “I worked as a volunteer some time ago and I started my period while we were doing door-to-door visits in the community. I borrowed money to buy pads from a friend and the next day I put on two pads because I was so scared. Overtime, I told myself I won’t travel a long distance when I am on my period because I may bleed a lot and mess myself up. But what if I need to take a long-distance walk for work?” [Bongeka] “I don’t bleed so much but I have terrible period pains. What’s worse is that I stand almost all day at work and my cramps are such a distraction, but because you’re at work, you must be professional, but its torture” [Thandeka] Even when in public spaces, the quality of women’s participation is compromised in part by the physical and emotional ramifications of menstruation but also by the use of menstrual and pain management products that are unable to match the unpredictable nature of menstruation and the needs of women with heavy menstrual flows and extreme menstrual cramps. Data collected for this study as such, also illustrates that self-isolation during menstruation, though also conveyed as a personal preference that is routed in sociocultural beliefs held by some, also provides individuals with controlled environments wherein they can more efficaciously cope with menstrual needs and challenges and related material shortcomings. To this, participants emphasise the importance of gender-responsive and specifically, menstruation-friendly, environments that not only accommodate individuals’ menstrual needs and challenges but also anticipate the unpredictable nature thereof. Additionally, study participants emphasise the intergenerational nature of menstrual needs and by extension, the importance of ensuring universal access to essential menstrual resources. As articulated in Bathandwa’s recollection: “ I couldn’t attend the community meeting last month because my daughter stained her uniform at school that day, and she was so traumatised when she came back. They hadn’t received pads at school for the month and she had to use toilet paper. Unfortunately, we also didn’t have any at home but luckily, my neighbour was around so she gave us a pack”. Bathandwa’s sentiments and data collected from this study as a whole, in addition to demonstrating the inter-generational nature of menstrual needs, also highlight how inequitable access to essential resources shapes patterns of participation in schooling and community life for adolescents and adults alike. With equitable participation being the bedrock of any democratic pursuit therefore, this study identifies menstrual inequity as a threat not only to individuals’ health and wellbeing, but also to the pursuit of equity and democracy in institutions and society as a whole. 4. Conclusions and recommendations This qualitative study sought to explore patterns of adolescents’ and women’s access to essential menstrual resources and to discuss how menstrual inequity shapes individuals’ participation in public life. The study employed an interpretivist paradigm along with a phenomenological research design to collect and analyse data on the experiences of women living in Inanda and uMlazi in KwaZulu-Natal. Data collected for this study identifies patterns of limited access to essential menstrual resources among study participants. Alongside this, the data also reveals various mechanisms employed by individuals to navigate and cope with inadequate access to sanitary and pain management products as well as unsuitable sanitation facilities and infrastructure. Among the mechanisms employed by individuals are endurance, self-isolation, making use of unsafe or ineffective pain management mechanisms all of which are adopted in response to uncertain access to menstrual resources that effectively respond to the unpredictability and variation in individuals’ menstrual needs and challenges. Moreover, self-isolation employed in anticipation of and in response to these inadequacies is reinforced by socio-cultural beliefs which prescribe for individuals to limit their public participation during menstruation. As such, findings from this study affirm previous research propositions of the compromised participation of adolescents and women in public life and extends these findings by consolidating and connecting them to broader trends of menstrual inequity. By so doing, the study finds menstrual inequity to be a formidable threat to the achievement of equity and by extension the pursuit of democracy in key institutions and society as a whole. To this, the study gestures towards research and interventions that not only accommodate but anticipate the varied experiences and needs of individuals by securing universal access to essential menstrual resources within and beyond institutions. Recommendations : Findings from this study necessitate further research on the menstrual experiences of adult women and adolescents in and beyond institutions. In its current form, this field of study has garnered much-needed focus on school-going adolescents with limited exploration not only of adolescents’ out-of-school experiences but also on the experiences of adults. The study also points to the needs for institutions to implement policies and interventions that accommodate and anticipate individuals’ menstrual needs and challenges beyond the provision of sanitary products. This is recommended especially in light of the secrecy with which menstruation continues to be handled and the challenges that many individuals may be enduring in silence as a result of this. Corresponding author : Sinazo Nomsenge: [email protected] Declaration of conflicting of interest : The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Declarations Corresponding author Sinazo Nomsenge: [email protected] Declaration of conflicting of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding statement: The research on which this paper is based is funded through a grant from the Andrew W. Mellon Foundation (New York): (Grant Number 1910-07226). Ethical approval and informed consent statement: This study involved human participants and was reviewed and approved by Humanities and Social Sciences Research Ethics Committee of The University of KwaZulu-Natal (Approval No. HSSREC/00006993/2024). Verbal and written informed consent to participate in this study was also provided by study participants in accordance with the guidelines stipulated by the Belmont Report of 1979. Data availability statement The raw and processed data required to reproduce the findings presented in this paper are unavailable at this time as this data also forms part of an ongoing study. Author Contributions: The sole author of this paper was the only contributor to the compilation and writing of this paper. The author has read and approved the published on the final version of the article. References Alharahseh H, Pius A. A Review of key paradigms: positivism vs. interpretivism. Global Acad J Humanit Social Sci. 2020;2(3):39–43. Bapat M, Agarwal I. Our needs, our priorities; women and men from the slums in Mumbai and Pune talk about their needs for water and sanitation. Environ Urbanization. 2003;15(2):71–86. Bloem S. A sociological study of menstrual hygiene management in school in the Makana District, Easter Cape, South Africa. Makhanda: Rhodes University (unpublished disseration); 2021. Bobel C, Winkler I, Fahs B, Hasson K, Kissling E, Roberts T. The Palgrave Handbook of Critical Mnestruation Studies. Singapore: Palgrave Macmillan; 2020. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Pyschology. 2006;3(2):77–101. Campbell S, Greenwood M, Prior S, Shearer T, Walkem K, Young S, Walker K. Purposive sampling: complex or simple? Research case example. J Res Nurs. 2020;25(8):652–61. Chinyama J, Chipungu J, Rudd C, Mwale M, Verstraete L, Sikamo C, Sharma A. Menstrual hygiene management in rural schools of Zambia: a descriptive study of knowledge, experiences ad challenges faced by schoolgirls. BMC Public Health. 2019;19(16):1–10. Crankshaw T, Staruss M, Gumede B. Menstrual health management and schooling experience amongst female learners in Gauteng, South Africa: a mixed methods study. Reproductive Health. 2020;17(48):1–15. Crawford B, Johnson M, Karin M, Strausfeld L, Waldman E. The Ground on Which We All Stand: A Conversation About Menstrual Equity Law and Activism. Mich J Gend Law. 2020;26(2):343–88. Creswell J. Qualitative inquiry and research design: Choosing among five approaches. 2 ed. ed.). Thousand Oaks, California: Sage; 2007. Dawadi S. Thematic Analysis Approach: Astep by step guide for ELT Research Practitioners. J Nelta. 2020;25(1–2):62–71. Elhami A, Khoshnevisan B. Conducting an Interview in Qualitative Research: The Modus Operandi. MEXTESOL J. 2022;46(1):1–7. Fennie T, Molestane M, Padmanabhununni A. Adolescents' experiences of menarche and menstruation in disadvantanged schools in South Africa: a qualitative exploration. Health Educ. 2021;121(4):408–19. Gearing R. Bracketing in research: A typology. Qual Health Res. 2004;14(10):1429–52. Hennegan J, Kibira P, Exum N, Scwab K, Makumbi F, Bukenya J. I do what a woman should do': a grounded theory study f women's menstrual experiences at work in Mukona District, Uganda. BMJ Global Health. 2020;5:1–11. Hennegan J, Winkler I, Bobel C, Keiser D, Hampton J, Larsson G, Mahon T. Menstrual health. Sex Reproductive Health Matters. 2021;29(1):31–8. Høffding S, Martiny K. Framing a phenomenological interview: what, why and how. Phenomenology Cogn Sci. 2016;15:539–64. Kaur R, Kaur K, Kaur R. Menstrual Hygiene Management and waste disposal: practices and challenges faces by girls/women of developing countries. J Environ Public Health. 2018;2018:1–9. Kivunja C, Kuyini A. Understanding and Applying Research Paradigms in Educational Contexts. Int J High Educ. 2017;6(5):26–41. Macleod C, du Toit R, Paphitis S, Kelland L. Social and structural barriers related to menstruation across diverse schools in the Eastern Cape. South Afr J Educ. 2020;40(3):1–9. Patel K, Dwivedy S, Panda N, Swain S, Pati S, Palo S. Is the menstrual cup a sustainable and safe alternative in menstrual hygiene management? A qualitative exploratory study based on user's experience in India. Clin Epidemiol Global Health. 2023;20(101212):1–5. Pervin N, Mokhtar M. The interpretivist Research Paradigm: A Subjective Notion of a Social Context. Int J Acad Res Progressive Educ Dev. 2022;11(2):419–28. Qutoshi S. Phenomenology: A Philosophy and Method of Inquiry. J Educ Educational Dev. 2018;5(1):215–22. Ruslin MS, Rasak M, Alhabsyi F, Syam H. Semi-structures Interview: A Methodological Reflections on the Development of a Qualitative Research Instrument in Educational Studies. IOSR J Res Method Educ. 2022;12(1):22–9. Somerville P. Democracy and participation. Policy Politics. 2011;39(3):417–37. Sommer M, Chandratna S, Cavill S, Mahon T, Phillips-Howad P. Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries. Int J Equity Health. 2016;15(86):1–5. Sumpter C, Torondel B. A systematic review of th health and social effects of Menstrual Hygiene Management. PLoS ONE. 2013;8(4):1–15. Thomas B. The Role of Purposive Sampling Tehcnique as a Tool for Informal Choices in a Social Sciences in Research Methods. Just Agric. 2022;2(5):1–8. Truyens C, Wilmouth R, Buckley C, Turnberg W, Daniell W. (2013). Menstral Management in communal sanitation facilities: recommendation to eThekwini Municipality. Nakuru: 36th WECD International Conference. Footnotes R2 (2 South African Rands) = 0,11 US Dollars Additional Declarations Competing interest reported. The author declares no conflict of interest. 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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-5432759","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":387508401,"identity":"5a428cc9-9d75-494d-b554-8caf63c712db","order_by":0,"name":"Sinazo Nomsenge","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4ElEQVRIiWNgGAWjYFAD9gZmUrXwHCBZi0QCkVrM2buTP3zcUSsnP/ONseHPHQzy/A3sDz/g02LZc3ab5Mwzx40NbucYJ0ieYTCccYAhWQKfFoMbuduYeduOJW6QzjE+YNjGwLiBgeEAIS2bP/9tO1Y/f+YZ4wOJbQz2GxgYm38Q0LJBmrGtJoHhBo9xwsE2hsQNDMxs+G05A/RLb9sBww1n0ooNG9skkmccZmOzwKvleO/mDz/b6uTl2w9vlvzZZmPb397++AY+LVBwGMYAOonI6KkjTtkoGAWjYBSMTAAAus1Kn/2eZFYAAAAASUVORK5CYII=","orcid":"","institution":"University of KwaZulu-Natal","correspondingAuthor":true,"prefix":"","firstName":"Sinazo","middleName":"","lastName":"Nomsenge","suffix":""}],"badges":[],"createdAt":"2024-11-11 14:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5432759/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5432759/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71601231,"identity":"d00065e5-505c-4469-afe7-a1766ea5c116","added_by":"auto","created_at":"2024-12-17 05:33:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":420954,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5432759/v1/a0904e37-5a29-461a-87a3-de64e29f9b6c.pdf"}],"financialInterests":"Competing interest reported. The author declares no conflict of interest.","formattedTitle":"Menstrual inequity: the ‘stain’ on participation and democracy in South Africa","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMenstruation is a characteristic of reproductive development that is experienced by 1.8\u0026nbsp;billion individuals with experience thereof being shaped by individuals\u0026rsquo; access to essential material and nonmaterial resources, often referred to as \u003cem\u003ehardware\u003c/em\u003e and \u003cem\u003esoftware\u003c/em\u003e menstrual resources (Bobel, et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Foremost among these is access to suitable Menstrual Hygiene Products (MHPs), related disposal and/or laundering facilities as well as pain and comfort management resources. Alongside this, menstruating individuals require sustained access to water, sanitation and hygiene resources, accurate and empowering menstrual education as well as supportive environments that enable safe and comfortable menstrual management (Sumpter \u0026amp; Torondel, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Hennegan, et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnfortunately, these resources remain inaccessible for many. Research conducted over the past two decades especially demonstrates how inadequate access to menstrual resources compromises individuals\u0026rsquo; physical and psychological health thereby significantly impeding on their ability to engage equitably and productively in public life (Macleod, du Toit, Paphitis, \u0026amp; Kelland, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Bloem, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fennie, Molestane, \u0026amp; Padmanabhununni, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For many adolescents, the lack of access to menstrual resources disrupts attendance and participation in schooling with studies suggesting that even among those who are able to attend school during menstruation, participation in educational and school-based social and physical activity is significantly disrupted (Chinyama, et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Crankshaw, Staruss, \u0026amp; Gumede, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition to having limited access to suitable or preferred menstrual and pain management products, water and sanitation facilities at many schools remain unsuitable for safe, healthy and comfortable menstrual management. Additionally, broader sociocultural belief systems constrain the circulation of accurate and empowering information about menstruation with secrecy and stigma characterising the experiences of many (Fennie, Molestane, \u0026amp; Padmanabhununni, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Patel, et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn and beyond schooling environments, menstruation continues to be shrouded in secrecy and stigma with material shortcomings compounding the complexities with which adolescents and adults must contend in managing their menstruation. Studies from various contexts suggest for example, that compliance to socio-cultural prescripts of menstrual etiquette compels adult women to manage their menstruation with secrecy often to the detriment of their health, safety and comfort (Hennegan, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Additionally, many women in resource-deprived communities cope with inadequate access to menstrual resources by making use of alternative materials to absorb menstrual blood and by employing various menstrual concealment practices that disrupt their comfort and engagement in personal, public, educational, social and economic activity (Bapat \u0026amp; Agarwal, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Research has also found that places of employment are often ill-equipped to accommodate the menstrual needs of individuals thereby compelling many to employ unhealthy and uncomfortable coping mechanisms that disrupt work attendance and participation (Sommer, Chandratna, Cavill, Mahon, \u0026amp; Phillips-Howad, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Hennegan, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithin this field of research, studies have therefore not only identified the material and nonmaterial resources needed for healthy experiences of menstruation, but they have also uncovered the dire consequences of inadequate access to these resources on individuals\u0026rsquo; health, safety, comfort and overall wellbeing. Moreover, scholars have inadvertently alluded to the implications of inadequate access to menstrual resources on academic, economic and socio-developmental participation. This paper seeks to extend this line of inquiry by consolidating and outlining the consequences of menstrual inequity on the patterns of participation in schooling, work, social and developmental activity among adolescents and adult women living in Inanda and uMlazi in South Africa\u0026rsquo;s KwaZulu-Natal Province. The paper goes on to opine on the implications of these patterns of participation on democracy within these institutions and in society at large. By so doing, the paper gestures towards the need for broader interrogations of menstrual inequity that accompany the localised explorations of menstrual experiences that have largely characterised the field thus far.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Problem Statement\u003c/h2\u003e \u003cp\u003eSomerville (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e: 417) recounts democracy to be largely understood as \u0026ldquo;an ideal or principle, namely that of popular equality\u0026rdquo;. Crawford, et al., (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e: 344) go on to suggest that given that menstruation is uniquely experienced by a subset of the global population, \u0026ldquo;only an equity approach can ensure that menstruators have safe and affordable access to the menstrual hygiene products they need in order to be full participants in society\u0026rdquo;. And indeed, menstrual research has largely sought to expound on the needs of individuals who menstruate with increased focus on the intersection of needs and vulnerabilities incurred by individuals who come from low socioeconomic settings. Research has especially honed in on the consequences of the lack of access to menstrual resources among adolescents and working women in Low to Middle Income Countries (LMICs) (Bobel, et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These consequences include interrupted school and work participation among adolescents and women respectively. While these have been considered in isolation from one another, taken together, research has demonstrated how disrupted academic and socioeconomic participation both flow from the same societal trends of inadequete access to essential menstrual resources. While doing so, studies have however, failed to consider the broader societal implications of these intergenerational complexities on patterns of participation and subsequently, the realisation of democracy in institutions and society as a whole. This paper contends with this gap by exploring adolescents and women\u0026rsquo;s participation in academic, social and economic activities and discussing the implications thereof on the realisation of equitable participation and democracy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Research Questions\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study explores how menstrual experiences shape patterns of academic, economic and sociodevelopmental participation among adolescents and women in KwaZulu-Natal. Adolescent\u0026rsquo;s and women\u0026rsquo;s access to essential menstrual resources is explored along with the ways in which their patterns of access to these resources shape their menstrual experiences and subsequently, their participation in public life. As such, the study is guided by the following core research questions:\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn what ways are menstrual experiences influenced by patterns of access to menstrual resources?\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHow does access to menstrual resources influence individuals participation in public life?\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2. Methodology","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Research Paradigm\u003c/h2\u003e \u003cp\u003eThis study was informed by an interpretivist research paradigm which, according to Alharahseh \u0026amp; Pius (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) concerns itself with the subjective realities of individuals, the meanings that individuals construct about these realities and how they are experienced and interpreted. Unlike positivism which seeks to establish universal explications of reality, interpretivist research delves into the variety of encounters with reality and the interpretations thereof (Kivunja \u0026amp; Kuyini, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Furthermore, Pervin \u0026amp; Mokhtar (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) suggest that interpretivist research is founded on the belief of social reality being informed by various contexts and individuals\u0026rsquo; subjective experiences of these contexts. Informed by the interpretivist paradigm, this study sought to provide detailed insight into individuals experiences, perceptions and ideas. The study was also aimed at detailing individuals\u0026rsquo; varied lived experiences and exploring the interpretations, meanings and ideas used to make sense of them. By so doing the study sought to draw out details about individuals\u0026rsquo; social contexts and to locate within these contexts, their menstrual experiences and implications thereof on their academic, economic and sociodevelopmental participation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Research Design\u003c/h2\u003e \u003cp\u003eThe interpretivist paradigm employed for this study along with the research questions, informed the adoption of a phenomenological research design. Asserting it as both a philosophy and method of inquiry, Qutoshi, (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) proposes phenomenology to be an approach suitable for developing a broader and deeper understanding of reality. Citing Gearing (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), Qutoshi (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e: 217\u0026ndash;218) goes on to suggest that phenomenology facilitates the careful examination of a phenomenon as it is experienced and perceived by individuals and does so through in-depth explorations of the ideas and interpretations used by individuals to make sense of said phenomenon. This approach was adopted for this study as it aligns with its core research questions and was deemed a suitable approach for responding to the core aims thereof. In particular, the approach facilitated a detailed exploration of the phenomena that are foundational to this study namely, menstrual inequity and participation. The approach was also a salient framework to be used to facilitate a detailed inquiry into the experiences and interpretations of said phenomena.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Population and Sample\u003c/h2\u003e \u003cp\u003eThis study was conducted with members of township communities, uMlazi and Inanda in South Africa\u0026rsquo;s KwaZulu-Natal Province. Adult women aged 25years and above were purposively sampled to participate in the study with the final participant pool consisting of 15 women aged between 26\u0026ndash;52years. As recommended by Campbell, et al., (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) a purposive sampling technique is suitable for the: \u0026ldquo;matching of the sample to the aims and objectives of the research, thus improving the rigour of the study and trustworthiness of the data and results\u0026rdquo;. As such, this study sought to sample individuals who would be better placed to provide data related to the phenomena under investigation. This is to say that this sampling technique was chosen with the aim of sampling individuals who may be better able to share and recount on personal experiences and perceptions related to the subject matter (Thomas, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this case, women who have personal experiences with menstruation from within the chosen research sites were purposively sampled to participate in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Collection Tools/instruments\u003c/h2\u003e \u003cp\u003ePrior to the collection of data, the study was presented to prospective participants with information sheets being distributed in order to allow individuals to carefully consider their decision to participate in the study and the implications thereof. Individuals interested in participating were required to read, understand and sign an informed consent form which provided details about the study, the risks and benefits of participating as well as the voluntary nature thereof. Interested individuals were also advised of their freedom to withdraw from the study at any time and without any consequences to their access to services and/or resources. After demonstrating an understanding of the study and consenting to participate, individual interviews were then scheduled and conducted in participants\u0026rsquo; most preferred language. With consent from participants, interviews were audio recorded after which they were transcribed verbatim and translated into English where necessary.\u003c/p\u003e \u003cp\u003eSemi-structure interviews were the chosen mode of interviewing for this study as, according to Elhami \u0026amp; Khoshnevisan (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), this mode of interviewing allows for a detailed exploration that is guided by topic areas derived from the research questions and reviewed literature. The flexible yet adaptable nature of semi-structured interviews is, according to Ruslin, et al., (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) ideal for qualitative research as it allows the interviewers to determine the depth of engagements with participants while also providing sufficient adaptability to the unpredictable nature of participant responses. As such, this mode of interviewing was considered ideal for this study in order to explore themes already established in reviewed literature but to also explore emerging themes, ideas and experiences within the chosen research context and among the sampled participants. This mode of interviewing was also guided by the phenomenological paradigm which informed the use of open-ended questions to explore the areas of interest derived from the research questions and reviewed literature (H\u0026oslash;ffding \u0026amp; Martiny, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This paradigm underpinned the implementation of this semi-structured interview method in order to explore participants\u0026rsquo; perceptions, ideas, memories, experiences and recollections.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data Analysis\u003c/h2\u003e \u003cp\u003eThematic analysis is defined by Dawadi (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e: 62) as a \u0026ldquo;qualitative research [analysis] method that researchers use to systematically organise and analyse complex data sets\u0026rdquo;. This analysis method \u0026ldquo; involves the identification of themes through careful reading and re-reading of the trascribed data\u0026rdquo; (ibid). As recommended by Braun \u0026amp; Clarke (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), this mode of analysis can be utilised inductively and deductively which indicates that pre-established themes (or codes) can be used to guide the analysis of a data set and data can be also analysed through codes that are obtained from patterns and themes emerging from the data set. In light of this, data collected for this study made use of both inductive and deductive thematic analysis in order to guide the analysis of data with the use of pre-established themes while also allowing the data to inform the establishment of themes. This analysis process was implemented with the use of the qualitative data analysis software, Atlas.ti.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethical Consideration\u003c/h2\u003e \u003cp\u003eEthical approval\u003c/strong\u003e to conduct this study was obtained from the University of KwaZulu-Natal\u0026rsquo;s Humanities and Social Sciences Research Ethics Committee (Protocol HSSREC/00006993/2024). With permission from local leaders, the study was presented in-person to prospective participants and interested individuals were invited to complete and sign consent forms prior to participating in interviews. After obtaining verbal and written consent to be interviewed, interviews were scheduled to align with participant\u0026rsquo;s availability. The collection and analysis of In order to preserve participant\u0026rsquo;s anonymity, no personal information was recorded for the study and pseudonyms are used when reference is made to participants\u0026rsquo; views and responses.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Presentation of Results and Discussion","content":"\u003cp\u003eData collected for this study sought to explore patterns of access to essential menstrual resources in order to illustrate the trends of menstrual inequity within the chosen research sites. The study was also aimed at exploring how patterns of access to menstrual resources shape women\u0026rsquo;s experiences of menstruation and ultimately, their patterns of participation in academic, economic and socio-developmental activity. With the view of addressing the research questions of this study, data collection was centred on literature-based themes and sub-themes as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAccess to Essential Menstrual Resources\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMenstrual Hygiene Products\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWater, Sanitation \u0026amp; Hygiene Facilities\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePain Management\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEducation and Support\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMenstrual Experiences and Participation in Public Life\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAdditionally, the following sub-themes emerged from data collected and were used to further organise and analyse the data set:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSocial Participation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAcademic Participation\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEconomic \u0026amp; Developmental Activity\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Essential Menstrual Resources\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWomen\u0026rsquo;s menstrual experiences are significantly impacted by their access to essential material and non-material resources. As does literature reviewed, data collected for this study identifies several material resources that are essential for the safe and comfortable management of menstruation. For study participants, access to sanitary pads and pain management products is deemed to be especially integral for sustaining comfortable menstrual experiences. For some, access to these resources is consistent while for a greater majority, access remains uncertain. With disposable sanitary pads being the most preferred menstrual hygiene product for all participants sampled, affordability was identified as the primary factor determining one\u0026rsquo;s ability to comfortably manage their menstruation with broader socioeconomic status being the underlying context of one\u0026rsquo;s affordability. Likewise, access to preferred pain management products is identified as paramount to one\u0026rsquo;s menstrual management although remaining uncertain for many. Affirming this, several participants recall instances of being unable to access sanitary and pain management products during menstruation with Bongi recalling a recent personal experience by saying: \u003cem\u003e\u0026ldquo;The shop was very close, we just did not have money; pads were also cheap because you were able to buy one pad for R2\u003c/em\u003e\u003csup\u003e1\u003c/sup\u003e, \u003cem\u003ebut I did not even have that R2\u0026rdquo;\u003c/em\u003e. Similar experiences and observations are shared by several other participants as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If you go to the shops you will find that only some women buy them. I do not even know how much they cost because I myself, cannot afford them.\u0026rdquo;\u003c/em\u003e [Lilitha]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My neighbour\u0026rsquo;s children get their pads from me because they cannot afford them; they cannot even afford to buy food so I help them out with pads because they are a necessity for a woman.\u0026rdquo;\u003c/em\u003e [Zama]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If I don\u0026rsquo;t have money for painkillers, I will have to endure until I\u0026rsquo;m fine; even my daughter, she has to endure until the end of her period\u0026rdquo;\u003c/em\u003e [Thobeka]\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants\u0026rsquo; experiences and recollections thereof illustrate how uncertain access to essential menstrual resources significantly shapes menstrual experiences for better or worse. Additionally, what data collected for this study also demonstrates is the intergenerational nature of experiences of menstrual inequity with adolescents and adults being significantly impacted in varied ways. Reflecting on this, participants in this study also shared personal experiences and observations of how they and others navigate and cope with the constraints that complicate their menstrual management. In the main, making use of alternative materials to manage menstrual blood and asking neighbours and friends were the primary coping mechanisms shared by participants with Zama highlighting the indignity of the latter by saying: \u0026ldquo;\u003cem\u003eI shouldn\u0026rsquo;t have to go around begging people for pads\u0026rdquo;\u003c/em\u003e. To this, other participants elaborate on their own experiences and observations as follows:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My daughter used to attend a local school where they did not get pads, so if I did not have money, I asked other girls who got pads from their schools\u0026rdquo;\u003c/em\u003e [Lilitha]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There are people who struggle to access menstrual products, for instance my friend\u0026hellip;sometimes she gets her periods when she does not have pads and I don\u0026rsquo;t have them either. It gets difficult because she ends up going to people\u0026rsquo;s houses to ask for them. Imagine asking for pads when you are an adult woman?! That\u0026rsquo;s not right.\u0026rdquo;\u003c/em\u003e [Mandlakazi]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In tough times, when you don\u0026rsquo;t have anything else to use\u0026hellip;you rush to get the newspaper, you soften it and put it on. Sometimes we use cloths while we are trying to make means to buy pads\u0026rdquo;\u003c/em\u003e [Bomi]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes people don\u0026rsquo;t say that they can\u0026rsquo;t afford pads because they fear that people will laugh at them for using cloths, towels or tissues because they cannot afford a pad.\u0026rdquo;\u003c/em\u003e [Zingce]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I have a friend who sometimes goes to the local tuckshops and asks to get pads on credit. Others end up getting into prostitution to try and make a living; you\u0026rsquo;ll hear them saying, \u0026lsquo;I can\u0026rsquo;t even buy myself pads\u0026rsquo;\u0026rdquo;\u003c/em\u003e [Nonkuleko]\u003c/p\u003e\u003cp\u003eThese and other sentiments shared by participants in this study highlight not only the dire state of menstrual inequity but also the indignity thereof. Moreover, in the case of uncertain access to effective and preferred pain management products, endurance along with several home remedies were shared as coping mechanisms employed by participants. While some indicated that they often endure the pain until the end of their period (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;6) others shared home remedies that they make use of including either drinking warm water with lemon juice, plain hot water or strong black coffee, chewing on cloves or using a hot water bottle or heating pad. While the effectiveness of these home remedies was confirmed by only a few participants (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;3), access to effective diagnosis of cases of excessive bleeding and extreme menstrual cramps was confirmed by none, with two participants noting:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I went to the clinic to ask them if this amount of bleeding is normal, they just gave me pain killers that didn\u0026rsquo;t even help with the cramps or the bleeding\u0026rdquo;\u003c/em\u003e [Sinakokonke]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eCramps and over-bleeding are a struggle for many of us; you can go to the clinic to get help and you\u0026rsquo;ll have to wait in a long line all day just to get Pain Block which does not help with those extreme pains.\u0026rdquo;\u003c/em\u003e [Lilitha]\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIn addition to these complexities encountered as a result of insufficient access to preferred sanitary and pain management products, women sampled for this study also convey experiences related to infrastructural shortcomings in their homes and communities that complicate their menstrual management as well as their overall health and wellbeing. In particular, inadequate access to water, sanitation and hygiene facilities obstructs the proper disposal of sanitary products as well as women\u0026rsquo;s privacy, safety and their overall hygiene management needs during and beyond menstruation. For some participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9), consistent access to clean water remains an elusive ideal the absence of which significantly impedes on basic menstrual and general health management. Additionally, the lack of disposal amenities, soap and sanitary infrastructure that enables privacy, comfort and safety underscores uncomfortable, unhealthy and unsafe menstrual management experiences.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Every day around 7pm our water gets cut until the next morning around 5am. So, you can\u0026rsquo;t flush the toilet or change pads\u0026hellip; EVERYDAY [participant emphasis]. It\u0026rsquo;s been over 20 years now\u0026hellip;Imagine if you have an accident in the middle of the night? that\u0026rsquo;s why we have to keep bottles to store water.\u0026rdquo;\u003c/em\u003e [Mbalenhle]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In the informal settlements, even the showers are for everyone. Even if they were separated, still they will use the same toilets\u0026hellip;the rape will be high in those communities because those toilets usually don\u0026rsquo;t have proper locks or lighting and girls also use them. A parent can say \u0026lsquo;go to the toilet, it\u0026rsquo;s okay because I\u0026rsquo;m close-by in the house\u0026rsquo;. Yet, they don\u0026rsquo;t know what happens to the child in the toilet.\u0026rdquo;\u003c/em\u003e [Zama]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In some places, they share bathrooms; so imagine if a woman who is menstruating has bled a lot and they want to shower, they go to the container and find a queue. You now have to wait uncomfortably, imagine that.\u0026rdquo;\u003c/em\u003e [Zinzi]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Sharing this toilet with other people is a challenge because while I\u0026rsquo;m inside needing my privacy, the other person will not understand that\u0026hellip;Imagine being in the toilet changing a pad, and then a man comes in, maybe if the door does not close properly for some reason\u0026hellip;You will feel that discomfort because now there is a man in the toilet with you.\u0026rdquo;\u003c/em\u003e [Mandlakazi]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Here in the shacks, we all sleep in one space, there are no rooms so I have to make sure I bath quickly\u0026hellip;so I have to shout and tell them [family members] I am still busy so that they won\u0026rsquo;t come in. So, there is no privacy really, the children are up and down, you can\u0026rsquo;t have private space to do your things.\u0026rdquo;\u003c/em\u003e [Zodwa]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think there should be a limit to how many people can use a toilet; for instance, if there are 3 toilets, 10 people could be allowed to use one toilet and each household can be given a key for their toilet because it\u0026rsquo;s so easy to get infections if a lot of people use one toilet, especially for us, women.\u0026rdquo;\u003c/em\u003e [Nonhle]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipant responses and data collected for this study as a whole demonstrates the network of socioeconomic inequities that intersect at and inform women\u0026rsquo;s menstrual management experiences (Truyens, Wilmouth, Buckley, Turnberg, \u0026amp; Daniell, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Socioeconomic status which shapes women\u0026rsquo;s access to financial resources constrains the ability to secure essential sanitary and pain management products while broader housing, water and sanitation infrastructure impedes on the ability to comfortably and safely manage menstrual health and hygiene. In the absence of these essential resources, women employ less-than-ideal coping mechanisms and are at the mercy of gender-non-responsive sanitation facilities that compromise their menstrual and broader wellbeing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Menstrual inequity and participation\u003c/h2\u003e \u003cp\u003eGiven that menstrual experiences do not occur in a vacuum, this study also sought to explore how menstrual inequity \u0026lsquo;bleeds\u0026rsquo; into various aspects of adolescents\u0026rsquo; and women\u0026rsquo;s lives and particularly how it shapes individuals\u0026rsquo; participation in various public activities. Data collected for this study, in addition to highlighting that individuals\u0026rsquo; menstrual experiences are located with broader societal trends of inequity and socioeconomic scarcity, also points to the disruptions waged against adolescents\u0026rsquo; and women\u0026rsquo;s participation in public life. Among adolescents, findings from this study affirm previous research propositions of the negative impact of menstrual inequity not only on patterns of school attendance but also on the quality of participation therein.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is so sad to see a child getting their period and falling behind on their studies because they have cramps\u0026hellip;The government should make sure that every child can easily get pain medication because a lot of school girls experience cramps.\u0026rdquo;\u003c/em\u003e [Zinzi]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;When I started my period, I did go to school but on day one of my period, I was always told to go back home because I bled so much that the blood dripped down my legs\u0026hellip;it came to a point where I knew not to go to school during my menstruation because I was going to get sick.\u0026rdquo;\u003c/em\u003e [Mbalenhle]\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I wasn\u0026rsquo;t comfortable even when I was at school\u0026hellip;I was always nervous, wondering if I would be fine when I stand up, especially when I didn\u0026rsquo;t have another pad to change.\u0026rdquo;\u003c/em\u003e [Mandlakazi]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You sometimes find a child running to you in the morning asking to borrow a pad before they go to school. Now, imagine if they only have that one pad? they\u0026rsquo;ll be worried and uncomfortable at school all day\u0026hellip;it\u0026rsquo;ll affect them\u0026rdquo;\u003c/em\u003e [Phumeza]\u003c/p\u003e \u003cp\u003eAdolescents\u0026rsquo; uncertain access to essential menstrual and pain management products stems from broader socioeconomic constraints that \u0026lsquo;bleed\u0026rsquo; into their participation in schooling (Chinyama, et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Crankshaw, Staruss, \u0026amp; Gumede, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Bloem, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). For some adolescents, this results in sporadically or consistently missing schooling days while for many others, it culminates in compromised participation therein (Fennie, Molestane, \u0026amp; Padmanabhununni, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Likewise, adult women\u0026rsquo;s participation in employment as well as social and economic activity is significantly impacted by these same patterns of menstrual inequity (Hennegan, et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Data collected for this study indicates that many women self-isolate during menstruation largely as a result of inadequate access essential and preferred menstrual resources. For some women, especially those who experience heavy menstrual flows, the absence of preferred sanitary products elicits a fear of staining one\u0026rsquo;s clothes and by extension, having their menstruation being unduly disclosed to others. This, as described by study participants is a \u0026ldquo;shame\u0026rdquo; for which self-isolation provides both protection and a space to freely attend to any unpredictable menstruation-related occurrences.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I usually just stay at home when I\u0026rsquo;m menstruating. I only go out if I really have to. I don\u0026rsquo;t want to go anywhere even if there is an event happening somewhere in my community, I don\u0026rsquo;t go because menstruation is so unpredictable and the pads that I can afford may let me down at the wrong time and at least at home, I can change it or take a bath quickly.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAdditionally, pain and discomfort affirm participants\u0026rsquo; preferences of staying at home during menstruation with home being a place wherein one can privately tender to their physical and emotional needs while also coping with material inadequacies, privately.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I stay at home as much as I can during my period; it\u0026rsquo;s more comfortable and it saves me money. When I\u0026rsquo;m at home, I use a cloth that I wash and reuse later, but when I go out, I have to have pads that I change and throw away after a few hours\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAs suggested by study participants therefore, menstrual experiences and coping strategies employed in the face of inadequate resources shape the nature and quality of one\u0026rsquo;s engagements public life. This includes employment, church, social life and community work. Within these spaces, women must navigate menstrual pain and discomfort, alongside inadequate menstrual and pain management products. Several participants (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9) recount common personal or observed instances of engagement in work, church, social or other public activity being disrupted by negative menstruation-related experiences. Many of these experiences include elements of limited access to preferred menstrual or pain management products as well as inadequate sanitation facilities.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;A lot of people don\u0026rsquo;t have jobs but they still they need pads\u0026hellip;they may also be in serious pain and not have money to buy medication. And now they have to be up and down looking for work but they must also buy pads and medication?\u0026rdquo;\u003c/em\u003e [Lilitha]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I worked as a volunteer some time ago and I started my period while we were doing door-to-door visits in the community. I borrowed money to buy pads from a friend and the next day I put on two pads because I was so scared. Overtime, I told myself I won\u0026rsquo;t travel a long distance when I am on my period because I may bleed a lot and mess myself up. But what if I need to take a long-distance walk for work?\u0026rdquo;\u003c/em\u003e [Bongeka]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t bleed so much but I have terrible period pains. What\u0026rsquo;s worse is that I stand almost all day at work and my cramps are such a distraction, but because you\u0026rsquo;re at work, you must be professional, but its torture\u0026rdquo;\u003c/em\u003e [Thandeka]\u003c/p\u003e \u003cp\u003eEven when in public spaces, the quality of women\u0026rsquo;s participation is compromised in part by the physical and emotional ramifications of menstruation but also by the use of menstrual and pain management products that are unable to match the unpredictable nature of menstruation and the needs of women with heavy menstrual flows and extreme menstrual cramps. Data collected for this study as such, also illustrates that self-isolation during menstruation, though also conveyed as a personal preference that is routed in sociocultural beliefs held by some, also provides individuals with controlled environments wherein they can more efficaciously cope with menstrual needs and challenges and related material shortcomings. To this, participants emphasise the importance of gender-responsive and specifically, menstruation-friendly, environments that not only accommodate individuals\u0026rsquo; menstrual needs and challenges but also anticipate the unpredictable nature thereof. Additionally, study participants emphasise the intergenerational nature of menstrual needs and by extension, the importance of ensuring universal access to essential menstrual resources. As articulated in Bathandwa\u0026rsquo;s recollection:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI couldn\u0026rsquo;t attend the community meeting last month because my daughter stained her uniform at school that day, and she was so traumatised when she came back. They hadn\u0026rsquo;t received pads at school for the month and she had to use toilet paper. Unfortunately, we also didn\u0026rsquo;t have any at home but luckily, my neighbour was around so she gave us a pack\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eBathandwa\u0026rsquo;s sentiments and data collected from this study as a whole, in addition to demonstrating the inter-generational nature of menstrual needs, also highlight how inequitable access to essential resources shapes patterns of participation in schooling and community life for adolescents and adults alike. With equitable participation being the bedrock of any democratic pursuit therefore, this study identifies menstrual inequity as a threat not only to individuals\u0026rsquo; health and wellbeing, but also to the pursuit of equity and democracy in institutions and society as a whole.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Conclusions and recommendations","content":"\u003cp\u003eThis qualitative study sought to explore patterns of adolescents\u0026rsquo; and women\u0026rsquo;s access to essential menstrual resources and to discuss how menstrual inequity shapes individuals\u0026rsquo; participation in public life. The study employed an interpretivist paradigm along with a phenomenological research design to collect and analyse data on the experiences of women living in Inanda and uMlazi in KwaZulu-Natal. Data collected for this study identifies patterns of limited access to essential menstrual resources among study participants. Alongside this, the data also reveals various mechanisms employed by individuals to navigate and cope with inadequate access to sanitary and pain management products as well as unsuitable sanitation facilities and infrastructure. Among the mechanisms employed by individuals are endurance, self-isolation, making use of unsafe or ineffective pain management mechanisms all of which are adopted in response to uncertain access to menstrual resources that effectively respond to the unpredictability and variation in individuals\u0026rsquo; menstrual needs and challenges. Moreover, self-isolation employed in anticipation of and in response to these inadequacies is reinforced by socio-cultural beliefs which prescribe for individuals to limit their public participation during menstruation. As such, findings from this study affirm previous research propositions of the compromised participation of adolescents and women in public life and extends these findings by consolidating and connecting them to broader trends of menstrual inequity. By so doing, the study finds menstrual inequity to be a formidable threat to the achievement of equity and by extension the pursuit of democracy in key institutions and society as a whole. To this, the study gestures towards research and interventions that not only accommodate but anticipate the varied experiences and needs of individuals by securing universal access to essential menstrual resources within and beyond institutions.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eFindings from this study necessitate further research on the menstrual experiences of adult women and adolescents in and beyond institutions. In its current form, this field of study has garnered much-needed focus on school-going adolescents with limited exploration not only of adolescents\u0026rsquo; out-of-school experiences but also on the experiences of adults.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe study also points to the needs for institutions to implement policies and interventions that accommodate and anticipate individuals\u0026rsquo; menstrual needs and challenges beyond the provision of sanitary products. This is recommended especially in light of the secrecy with which menstruation continues to be handled and the challenges that many individuals may be enduring in silence as a result of this.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eCorresponding author\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eSinazo Nomsenge: [email protected]\u003c/p\u003e \u003cp\u003e \u003cb\u003eDeclaration of conflicting of interest\u003c/b\u003e:\u003c/p\u003e \u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSinazo Nomsenge: [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting of interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research on which this paper is based is funded through a grant from the Andrew W. Mellon Foundation (New York): (Grant Number 1910-07226).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and informed consent statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study involved human participants and was reviewed and approved by Humanities and Social Sciences Research Ethics Committee of The University of KwaZulu-Natal (Approval No. HSSREC/00006993/2024). Verbal and written informed consent to participate in this study was also provided by study participants in accordance with the guidelines stipulated by the Belmont Report of 1979.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe raw and processed data required to reproduce the findings presented in this paper are unavailable at this time as this data also forms part of an ongoing study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sole author of this paper was the only contributor to the compilation and writing of this paper. The author has read and approved the published on the final version of the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlharahseh H, Pius A. A Review of key paradigms: positivism vs. interpretivism. 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Reproductive Health. 2020;17(48):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCrawford B, Johnson M, Karin M, Strausfeld L, Waldman E. The Ground on Which We All Stand: A Conversation About Menstrual Equity Law and Activism. Mich J Gend Law. 2020;26(2):343\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell J. Qualitative inquiry and research design: Choosing among five approaches. 2 ed. ed.). Thousand Oaks, California: Sage; 2007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawadi S. Thematic Analysis Approach: Astep by step guide for ELT Research Practitioners. J Nelta. 2020;25(1\u0026ndash;2):62\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElhami A, Khoshnevisan B. Conducting an Interview in Qualitative Research: The Modus Operandi. MEXTESOL J. 2022;46(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFennie T, Molestane M, Padmanabhununni A. Adolescents' experiences of menarche and menstruation in disadvantanged schools in South Africa: a qualitative exploration. Health Educ. 2021;121(4):408\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGearing R. Bracketing in research: A typology. Qual Health Res. 2004;14(10):1429\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHennegan J, Kibira P, Exum N, Scwab K, Makumbi F, Bukenya J. I do what a woman should do': a grounded theory study f women's menstrual experiences at work in Mukona District, Uganda. BMJ Global Health. 2020;5:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHennegan J, Winkler I, Bobel C, Keiser D, Hampton J, Larsson G, Mahon T. Menstrual health. Sex Reproductive Health Matters. 2021;29(1):31\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eH\u0026oslash;ffding S, Martiny K. Framing a phenomenological interview: what, why and how. Phenomenology Cogn Sci. 2016;15:539\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaur R, Kaur K, Kaur R. Menstrual Hygiene Management and waste disposal: practices and challenges faces by girls/women of developing countries. J Environ Public Health. 2018;2018:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKivunja C, Kuyini A. Understanding and Applying Research Paradigms in Educational Contexts. Int J High Educ. 2017;6(5):26\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacleod C, du Toit R, Paphitis S, Kelland L. Social and structural barriers related to menstruation across diverse schools in the Eastern Cape. South Afr J Educ. 2020;40(3):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel K, Dwivedy S, Panda N, Swain S, Pati S, Palo S. Is the menstrual cup a sustainable and safe alternative in menstrual hygiene management? A qualitative exploratory study based on user's experience in India. Clin Epidemiol Global Health. 2023;20(101212):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePervin N, Mokhtar M. The interpretivist Research Paradigm: A Subjective Notion of a Social Context. Int J Acad Res Progressive Educ Dev. 2022;11(2):419\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQutoshi S. Phenomenology: A Philosophy and Method of Inquiry. J Educ Educational Dev. 2018;5(1):215\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuslin MS, Rasak M, Alhabsyi F, Syam H. Semi-structures Interview: A Methodological Reflections on the Development of a Qualitative Research Instrument in Educational Studies. IOSR J Res Method Educ. 2022;12(1):22\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSomerville P. Democracy and participation. Policy Politics. 2011;39(3):417\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSommer M, Chandratna S, Cavill S, Mahon T, Phillips-Howad P. Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries. Int J Equity Health. 2016;15(86):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSumpter C, Torondel B. A systematic review of th health and social effects of Menstrual Hygiene Management. PLoS ONE. 2013;8(4):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas B. The Role of Purposive Sampling Tehcnique as a Tool for Informal Choices in a Social Sciences in Research Methods. Just Agric. 2022;2(5):1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTruyens C, Wilmouth R, Buckley C, Turnberg W, Daniell W. (2013). Menstral Management in communal sanitation facilities: recommendation to eThekwini Municipality. Nakuru: 36th WECD International Conference.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e R2 (2 South African Rands)\u0026thinsp;=\u0026thinsp;0,11 US Dollars\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":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Menstruation, Participation, Democracy, Menstrual Equity, Sociology of Health","lastPublishedDoi":"10.21203/rs.3.rs-5432759/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5432759/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHealthy experiences of menstruation require access to material and nonmaterial resources including sanitation facilities, privacy and comfort infrastructure, hygiene and pain management products as well as accurate and empowering menstrual education. These resources remain inaccessible for many women and adolescents thereby compromising their participation in various aspects of their socioeconomic advancement including schooling, work, and personal development. For adolescents, inadequate access to essential menstrual resources compromises schooling experiences with research suggesting that in addition to many adolescents missing school during menstruation, the quality of their social and educational participation is significantly impeded by the lack of access to essential resources. Beyond this, limited access to critical resources and infrastructure interferes with women\u0026rsquo;s work and socioeconomic engagements in ways that compel many to employ menstrual concealment practices that compromise their health, comfort, safety, and ultimately, their equitable participation in social and economic activity. Moreover, stigma and secrecy surrounding menstruation limit open engagements about menstrual needs and challenges thereby making various aspects of society inherently inequitable and incapable of fostering democratic participation. This paper draws on qualitative phenomenological research conducted with 15 women living in uMlazi and Inanda in KwaZulu-Natal, South Africa. In-depth interviews were used to explore participants\u0026rsquo; experiences and perceptions on how menstrual inequity influences patterns of socio-economic, educational, and developmental participation among adolescents and women. From data collected, the paper suggests that inadequate access to essential menstrual resources shapes inequitable patterns of participation in schooling, work, social and developmental activity.\u003c/p\u003e","manuscriptTitle":"Menstrual inequity: the ‘stain’ on participation and democracy in South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-17 05:25:30","doi":"10.21203/rs.3.rs-5432759/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-13T21:40:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-07T21:52:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-02T08:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28589867174261568633896443642272683379","date":"2024-11-28T07:15:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15421525108780562701191801878784295704","date":"2024-11-27T13:06:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172969014126527944805099966438093004068","date":"2024-11-26T17:21:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-25T12:48:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-18T04:51:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-18T01:56:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2024-11-11T14:16:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5a195ec-f443-4fb4-98ba-35d177e78cef","owner":[],"postedDate":"December 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-24T08:08:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-17 05:25:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5432759","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5432759","identity":"rs-5432759","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}