Podcast Diaries: The Period Podcast S03E31 – BeYou Online

Podcast Diaries: The Period Podcast S03E31

Why we love this episode:

In this episode of The Period Podcast, Dr Clancy speaks to Dr. Julie Hennegan, a Research Associate at John Hopkins Bloomberg School of Public Health. They talk about menstrual hygiene management, and debunking assumptions that we make about the needs of menstruators.

Menstrual hygiene is a big topic for us here at BeYou HQ. From our cups to the BeYou Foundation, it’s an area which is often glossed over. While there have been strides in the right direction, there is still so much still to do. If you’ve not been following this series of podcasts with us then make sure you go and check it out on your favourite podcast app. Give it a listen by clicking play below or read along if that’s your vibe. You won’t regret it – this episode was amazing!

Listen & Learn:

Transcript:

I think menstrual hygiene is a complex topic with a lot of different components, but largely is about what does it mean to manage your period in different contexts and different settings and what influence does that have on your life?

This is Period Podcast, Episode 31. I'm Kate Clancy and I'm your host. I'm a biological anthropologist and intersectional feminist biologist, and a period enthusiast. You can find me on Twitter and Instagram as periodpodcast2. And that's my Gmail as well. I am so pleased to bring you this week's episode with guest, Dr. Julie Hennegan.

Dr. Julie Hennegan is a research associate at Johns Hopkins Bloomberg School of Public Health. She undertakes mixed methods research exploring the design and evaluation of complex social interventions for women's health. Dr. Hennegan leads multiple programs of menstrual health and hygiene research at Johns Hopkins, including a multicountry project to improve the definition and measurement of core constructs in menstrual health research.

In this episode, Dr. Hennegan and I talked about the concept of menstrual hygiene management, and how what we assume menstruators need isn't always what they actually need. I also really appreciated what Dr. Hennegan had to say about making sure that the evidence we collect on menstruation is good. You'll see what she means in the interview. So, let's have a listen.

Well first, thank you so much for joining me on Period P. But the first thing that I wanted to ask you was what was your path to becoming a scientist?

Well, I always loved science. I actually did my undergraduate degree in psychology and loved the research components of that, love more generally thinking about how things worked, love numbers, love that sort of approach to working out interrogating evidence and thinking about how we know what we know. I spent a few years after that doing other things. But after being overseas for a little bit, I started working at a place called the Queensland Center for Mothers and Babies in Brisbane, Australia. And they were looking at research to inform a women-centered approach to maternity care across the state of Queensland.

And that was when I really got to, I guess, have my first taste of working on research that was both using that sort of scientific skillset but applying it to thinking about how we can make policy or programming better and better meet the needs of the women that we're trying to serve. So, I thought that was fantastic and I loved my time there and thought that that was what I wanted to keep doing.

So, then I moved to the UK and did my master's in evidence-based social intervention at the University of Oxford, which is when I started looking at menstrual health and hygiene, that's the topic of my dissertation, and then I stayed there and did my PhD at Oxford on the same topic. And I guess haven't stopped thinking about periods.

Well, tell me how you got started thinking about periods specifically? I mean, when you were doing the maternal health work, was most of that work on cycling and periods? Or was it on maternal health and women's health more broadly?

No. It was on experiences of pregnancy, of antenatal childbirth care and postnatal care. So, not a menstrual component, but it was thinking about women's reproductive health, which is a topic that I have always been very passionate about. And then when I came to Oxford, I wanted to learn more about how we develop and use rigorous evidence to inform policy and practice. And I wanted to apply that to women's reproductive health because that was the topic I was passionate about.

And it actually was sort of one of those chance things where I had seen that in the department, there was a program of work happening around menstrual hygiene. It was originally in Ghana, and then they were doing a followup study in Uganda. And I thought that is really cool. So, I am going to work on that as a component of women's reproductive health. And then the more I did it, I guess the more I fell in love with that topic and felt that there's so much to be done in that space because it's been so under researched. So, I guess it was fortuitous that they were doing it and that that was sort of what I wanted to pursue.

So, just because our listeners might not be familiar with this term, what is menstrual hygiene?

Yeah. So, I should start with a caveat that menstrual health and hygiene or menstrual hygiene research is relatively new or recent. That means that some of the terms that we use to, or the definitions that we use for different topics are still evolving. That's just my caveat in that menstrual hygiene has meant a few different things. I think different people might have their own definitions of what that means.

But generally, it's about understanding how women and girls and people who menstruate experience their periods in their context. And a lot of menstrual hygiene research has focused on the experiences of those in low resource settings. So, I started off looking at menstrual hygiene in low- and middle-income countries, and really trying to understand what does it mean to manage your period in resource-constrained settings. A lot of the early work was around the struggles that girls in schools had managing that period.

Menstrual hygiene has a lot of different components. So, it's not just do girls have something to bleed on or to catch their menstrual bleeding? But also, do they have somewhere to change their menstrual materials? Is that a struggle for them? They don't have a private toilet are a private place at school to change their materials. They may not have somewhere to dispose of those materials that's sort of discreet and safe. It can mean that they don't have information or education about that period.

So, they might bleed for the first time and think that they're sick or think that they're dying because they don't know what's happening. There's a lot of stigma around women's reproductive health and menstruation. So, perhaps after they learn about menstruation, they're still not confident to talk to anybody about it. It's kept secret. They can't seek support from friends or teachers or parents about their period.

So, I think menstrual hygiene is a complex topic with a lot of different components. But largely is about what does it mean to manage your period in different contexts and different settings? And what influence does that have on your life?

And I imagine those of us for more western or industrialized contexts aren't necessarily thinking about all those different elements like what you've laid out, not just access to like you said some way to actually collect your menstrual period, but places to change it safely, places to dispose of it. I imagine access to clean water to clean yourself before after or wash your hands after you've been dealing with blood.

In an earlier episode, we talked to an evolutionary immunologist, Dr. Brinkworth, who talked about blood-borne pathogens and the fact that there's blood and menstrual blood, and so yes, we should be more careful about what we do with it. It's not a sterile substance necessarily. So, can you tell me a little bit, you sort of laid out some of the different things that people have to be thinking about when thinking about variation in menstrual management or menstrual hygiene. How does it actually vary across the globe?

You've said you've done some work in Ghana? Probably most of our listeners are again, probably western, probably from more industrial or urban settings, how might this lived experience look different?

Yeah. So, I should, I guess start by saying that even in high-income countries or westernized countries, there is increasing evidence that there are still populations who are experiencing difficulties managing their period. But in terms of the world, I think there are a lot of challenges, some of which I've mentioned. It's very easy to think about, oh, menstrual hygiene, that means you've got access to all the pads or tampons or menstrual cups that you want. And that's certainly a part of it.

I think, we have a lot of narratives from girls from NGOs, that they do struggle to access absorbance or something to catch their menstrual bleeding. So, that might be cloth that they've bought from the store if they've got funds to do that. It might be repurposed sort of cloth that they found around the house. It might be parts of the inside of a mattress if they're not confident to tell someone at home that they're menstruating and trying to find different sort of materials to use as an effective absorbent. They might not have a lot of pairs of underwear to place that sort of absorbent into.

It also means looking for a place to change that menstrual material. So, if you're using cloth, you probably need to change it more times a day if it's not as absorbent as a sanitary pad that a lot of listeners might be used to. So, that means if you're at school and the school doesn't have any toilets, or if they have toilets but they're quite dirty, they're sort of pit latrines and they smell or they don't have locks on the doors and you're really nervous that somebody's going to come in, that somebody is going to see you changing your menstrual materials, or see blood or your cloth in the toilet, if they're using it after you.

So, girls have reported being very stressed about those experiences not feeling safe or private in the places and that they might need to change their materials. And so, going home, at home, they may not have a latrine or toilet for the household. So, they might be using one that's in the community or they might be using their household facility, but they might still not want anybody in their household to know that they're menstruating.

If they're using reusable cloth, they then need to wash it so they need to find a basin. They need to find water and soap, just sort of clean that cloth. They need to find somewhere to dry it. And a lot of times, girls can be embarrassed about drawing the extra materials if it still has marks of period blood on it. So, they might dry it outside in the sun, but they also might sort of hang it underneath their ... In a sort of corner of the house or sort of under their mattress is what we've heard from some locations, that girls are drying that cloth because they don't want anyone to be able to see it or move it or take it.

And as I said, there's not just a physical component, but there's a knowledge component. So, knowing what's happening to you, that this is a regular thing, that the blood is coming from your reproductive organs, and it's not coming from your digestive tract or somewhere else, understanding the links between menstruation and pregnancy, so a lot of girls, or in some places, we hear that if a girl menstruated, that the community believes that means that she's had sex, which isn't the case. So, there can be a lot of fear and misinformation about that.

As well as taboos and expectations about what menstruating women and girls can or can't do. So, they may not be able to enter the kitchen or sit next to men or boys. They're sort of taboos and ideas about menstruating women interacting with crops or animals or other members of the household. And all of those sort of big array of factors influences what it might be like to have your period in different settings.

Yeah, absolutely. And so, I mean, you started with the fact that there's actually more variation than I think many of us realize, even in urban contexts.

Yeah.

And then detail some really important ways in which rural contexts and non-western or non-industrialized experiences might be different. Can we go back to variation and experience in urban contexts. I know certainly menstrual management around homelessness is an issue I've heard a lot about. Are there other things to think about in that arena?

So, I should say there's not a lot of evidence at the moment. A lot of what we're hearing in the last couple of years has been anecdotal. That means it's been sort of news stories or individual organization saying, "Yes, we're experiencing this in populations that we are working with. But we're hearing more and more narratives about those from even low socioeconomic status or those without a lot of resources, having trouble to afford enough menstrual products." So, not being able to afford sanitary pads or tampons and using them for a very long time or needing to use alternatives, needing to choose between purchasing menstrual materials and having money for food and other essential family needs.

As well as I think in the news, we've had quite a bit of information about the sort of use of menstrual products in correctional facilities and women having restricted access to the products that they need to manage the periods in those settings, as well as certainly homeless populations struggling to manage their period not having materials, often potentially not having a place to change them or store their materials. And we've certainly heard narratives from shelters and food bank type organizations that they are looking to supply menstrual materials to those who are struggling financially or those that are homeless.

A phrase that I'm hearing you say a lot is this phrase evidence or evidence base? And so, I wanted to first have you maybe talk a little bit more about what that means. And then to talk about why it is that it seems like the evidence base is so poor when it comes to thinking about menstrual hygiene management and really just a lot of women's health questions more broadly. So, first, what is an evidence-based public health approach to menstrual hygiene?

Sometimes it means being a sceptic. Or it can sound like I'm often being a sceptic. An evidence-based approach is just that. It's saying, "Well, let's use the best available methodologies and the most rigorous ways of trying to understand this problem and to evaluate whether what NGOs and governments are trying to do to address it is working." So, it's about not necessarily taking for granted that what we think is going to help those who are menstruating is actually going to work in the way that we expect and is going to have the impact that we think that it's going to have.

So, it's about using a range of different methods to better understand the problem and to generate evidence to understand, well, what are the difficulties that girls might experience during their period? It's not just the pads that they're using. We also have to think about all these other things, as well as thinking about well, is what different organizations are doing to address this working?

I think people like to receive free things or they're mindful that an organization is trying to help them. And they might have a positive experience of that, yes, someone came to the school. They told me about periods and I got free products. And that was great. And it's important that recipients are sort of favourably responding to the intervention, but that doesn't mean that that's the most effective use of the limited development funds that are available.

All of that is working to achieve the outcomes that we think it's working to achieve. Are girls selling those products? Are they not able to use them because there's no toilet? Are they embarrassed to have received menstrual products because it's exposed to their family or their peers that they're menstruating?

So, a lot of the time, taking an evidence-based approach is really about trying to use scientific and research evidence to inform better practice and to question a lot of our assumptions about how a problem is operating and why and if different interventions are working. And it means questioning what we think we know.

So, I think you've probably seen in a lot of news stories that report about menstrual hygiene. We hear this figure, one in 10 girls in Africa misses school because of her period. That number doesn't come from anywhere. There was no study that talked to a representative sample of girls in the whole continent of Africa to understand whether or not their periods was an instrumental factor in them missing school. So, we don't have any evidence to support that figure. And yet it gets sort of spread around perpetually, as this message that this means that one in 10 girls is missing school during their period.

So, I think taking an evidence-based approach means saying, "Well, where does that come from? How do we know that? Is the way that we know that reliable? And if not, then how can we actually get an accurate picture of whether or not girls are missing school because of their period? If so, what parts are managing them menstruation are contributing to that absenteeism? And then what can we actually do to improve that situation?"

So, I'm forgetting a second part of your question. Why is there not enough evidence?

Well, I guess just reflecting back some of what you're saying, is it seems to me that if we really want to be serving women and girls and other menstruating people best is that it's not enough to assume that we know what they need. And it's not enough to just sort of assume for instance, like you said that menstrual hygiene issues are keeping girls in Africa from school or that what the homeless population most needs is just more free pads and to really look at the entire issue of menstrual management and be more rigorous in our approach to understanding what's going on.

Now, one of the things that seems to get in the way of that is the fact that the evidence base is pretty terrible. And this is something as someone who just doesn't just study periods, but studies reproductive physiology more broadly, I feel like I'm continually coming up against is our evidence base is terrible. So, what is your approach? Why do you think the evidence base is so poor around issues of women's health and in particular, around menstrual hygiene management? And then how do you kind of handle that as you're moving forward in your own work?

Yeah. I mean, I think you've got it spot on. I think in terms of taking an evidence-based approach, it's in a lot of ways having humility and saying, well, we don't know. We can't assume to know what's going to work. We don't hand out drugs before we know what they do and test whether or not they work. And I still believe it should be similar when we hand out different social interventions or policies, that we should probably check that they're actually having the effect that we want them to have.

The difficulty, as you say, is that there's not enough research evidence and not enough funding to generate high quality evidence around a huge number of acts of women's reproductive health. I think there are probably a range of contributing factors, some of which are that women's reproductive health has been stigmatized and taboo. And so, we think it's icky, or, oh, well that's a private part of a woman's life and why would we be doing research on that. I think funding bodies and even researchers traditionally have been men.

And so, they haven't thought about it. I mean, we hear that in response to discussions about the tampon tax as well. So, why menstrual products taxes luxury products, and sometimes you just see the laws was written by men and they didn't really think about it.

So, I think sometimes it's been admitted because it's not been seen as a priority by male-dominated academic departments or funding bodies. I also think there's a component particularly when it comes to menstruation that it's quite taboo and stigmatized. People get funny talking about it, "Oh, we can't talk about periods. We can't talk about women bleeding. We just want to forget that that happens."

And so, that's meant that's not being talked about. It's only in the last 10 years that we've seen or maybe 15 years that we've seen more and more research about how are women and girls in the world are managing their periods. They didn't just start menstruating. They've been menstruating for many, many, many years now, and only now being able to talk about this.

So, I think part of it's this sort of stigma and taboo and silence around women's health. I also think that systematically, women's health topics are not seen as being as essential. They're saying, "Well, women aren't really dying from having difficulties managing that period." And so, there's this idea of, well, if it's not attached to mortality, is this a funding priority? And I've certainly come up against that in our research of saying, "Well, how can we improve the menstrual experiences of girls and women in different contexts is, well, how is this linked to morbidity and mortality?"

And I think some of that is tricky because many women and girls aren't dying, that doesn't mean that it's not significantly hampering their engagement in their social life or in education or in their economic empowerment.

I also wonder sometimes in those families or in those populations where silence around periods might actually lead to more shame, what does it mean to lead a significant portion of your life covertly and to live it with shame and to not understand why it's happening?

Yeah.

I don't know that we can put a number on how many health insurance dollars are going towards that or the morbidity and mortality estimates around shame, but I feel like they're probably pretty significant.

Yeah. And I think we're increasingly recognizing, well, it's also about well-being and mental health and the way that your relationship or experience of your body then translates into all the components of health that have, again, especially because it's about that have more of a stamp of approval from various funding bodies about being priorities, but how does your relationship with your body and understanding your menstrual cycle contribute to your successful use and seeking out of contraception and avoiding unwanted pregnancy, which is linked to maternal mortality in a lot of places.

So, I absolutely believe those links are there. But I also think that women are menstruating on average about 65 days a year, that's 18% of the time, that 18% of their lives matters. So, we need to be thinking about what that experience is meaning for them and how it is influencing their life. I also think there's this ongoing narrative everywhere almost that, well, you sort of suffer in silence.

Even if you're having menstrual pain or difficulties with your period, you wouldn't go around the office telling people that a lot of women are sort of, "Well, I just need to pretend like nothing's wrong." And then it's all, "I just keep it to myself. If I'm having cramping, then I'm not going to show anybody that that's happening." And I think that's detrimental. It means that we're constantly hiding whatever burden there might be associated with menstruation in society.

Absolutely. So, what kind of resources then? We've talked about the fact that an evidence base is incredibly important to understanding the problem and figuring out solutions. But we've also talked about the fact that the evidence base is frankly terrible. So, what is the kind of research or the kind of information that you think activist groups, nonprofits and NGOs need in order to do their best and most effective work around menstrual hygiene management across the globe?

So, that's a big question that I could talk about for a very long time. I mean, I think there's a lot of information that we need. I mean, there's sort of the two parts that we've spoken about broadly in terms of understanding the problem. What are the parts of menstrual experience that are causing a problem for women and girls? Is it just that they don't have menstrual materials to sort of bleed on or absorb menstrual bleeding? Or is it also this aspect of sanitation facilities and these other parts of experience that are important? Is it only a lack of knowledge and how is that contributing?

So, I think that NGOs and actors need an understanding of those different components, as well as, as we've discussed information about what are the kind of programs that have worked? What kind of education have other people developed? What's been tested? What have we been able to trial and see whether or not it's effective and refine over time. I should say NGOs or actors in the field are always going to be combining research evidence with the specific needs of their population and their own expertise.

When we talk about evidence-based practice is often this diagram of sort of three overlapping circles or a Venn diagram where we have the most rigorous evidence that we can generate about perhaps overarchingly what works or just providing products work, and how does that work for who might at work? And then practitioners, I hope, ideally, I guess, together with researchers will think about, "Well, is that applicable to this population? Does it meet the needs of the population and how does that sort of combine with that professional experience in the field for this particular group?"

So, it's not just that we need to generate evidence at a global level and then every NGO should apply exactly that everywhere. I think we know that that's not what an evidence-based approach looks like or how it should work. However, we do need more information about in what kinds of populations does providing free sanitary pads work or not work? What are the potential unintended consequences of that, that organizations would need to monitor or think about if they're going to implement that?

Is it stigmatizing to girls are putting them at risk by identifying them as menstruating girls by giving them products and what does that mean for an NGO's community? What kind of outcomes can we expect to see if we do these different kinds of programming based on ways we've been able to test this rigorously in similar or in other settings and thinking about how they can apply that knowledge to their population.

I mean, I think there's a lot more detail we need to know about how products work, what information is needed, what kind of sanitation facilities support girls and just providing them change things. How do we address menstrual stigma effectively? I think we talk about the stigma around menstruation a lot. But we don't really talk that much about what it would mean to reduce menstrual stigma.

Exactly, exactly. What I really appreciate about the way that you are defining evidence base is that you're talking about the ways in which it's locational and contextual. And it's not just a bunch of scientists gathering very, very large sample sizes, though that is obviously one form of evidence and very important, but also that it involves listening to practitioners, and obviously people with the lived experiences that we're trying to serve.

That's definitely another really big frontier right now is thinking about ending periods stigma. And I agree with you that it's not something I think we've fully thought through. Those of us who think about periods or menstrual hygiene more specifically, what are even some of the first questions we need to be asking in order to do a better job thinking about how that intersects with how effective our different menstrual hygiene interventions can even be?

Yeah. So, I mean, I think it's a really complex question. I think we can think about the different ways that menstrual stigma manifests in keeping women and girls from information, in keeping research from happening about what works in, in how we speak to each other about periods, about how freely women can let other people know that they're menstruating, what the social consequences or social norms are around sharing that information and the way that we expect women to act during their periods.

And I think that might manifest differently in different contexts. And we might be dealing with different challenges in different contexts. So, perhaps here in the US, we're thinking about, "Well, if I'm having cramps and I'm going to the office, can I openly use a hot water bottle? And what would it mean to do that? What would it mean for people to know that I'm menstruating?" And how it is simply the act of women saying, "Well, we're going to be more open about this now," going to reduce stigma around that saying, "Well, if it becomes more normal, if we become more open in speaking about this, how is that going to translate into a reduction in stigma?"

What I think about first when I think about that is sometimes it's going to matter how we talk about it. Because I think for a long time, menstruation has also been used as an excuse to keep women out of the workplace or just say that they can't do things or that they Are Emotional or that well, she's menstruating, and so her decision making is compromised.

I think there's a lot more we need to understand to combat that with evidence and say, "Well, what does the menstrual cycle really mean for women's lives? Is it something that we optimize at different times? Everyone feels differently on different days and women actually have more insight into that because of the menstrual cycle that can help them be more effective. Does it mean that or does it not have an effect on anything?" And so, we just need to be clear about the way that pain and menstrual bleeding is managed.

Right. I think there are a lot of open questions.

The first episode of season three actually, I interviewed Dr Annalise Beery at Smith, I don't know if you're familiar with her work or not, but she's done a lot of really amazing work to show that a lot of our assumptions about the menstrual cycle and how variation of the menstrual cycle just wreaks havoc with women's cognition and emotions and it does all these things to us. And at least in her rodent studies or her reviews of a lot of urban studies have shown that the menstrual cycle or the oestrus cycle doesn't actually do a whole lot to really very many variables at all.

So, this constant invocation of, one, it's too hard to study animals are individuals with oestrus cycles or menstrual cycles is false, but two, the idea that we're so variable and so pushed and pulled by these different hormones is not true. And in fact, across some variables, men or males are actually more variable than females.

Yeah.

I do think there are a handful of phenomena that we do experience through the menstrual cycle that are tied to cycling, that are tied to ovarian and endometrial functioning and hormones. But a lot more of it is completely untied and I feel like that's another thing that we don't have a strong enough evidence base for we've developed a lot of assumptions around and that is one of the things that's limiting us in being able to have a lot of conversations openly, as you say, around menstruation and the menstrual stigma.

Yeah, because there's these myths that have sort of perpetuated over time or been weaponized against women and this idea that the menstrual cycle is a limiting factor on us. So, I think it's a tricky line. I think we need more evidence like that to say, "Well, actually, that doesn't hold water." And these are this sort of experiences that women have during their period and it's normal. And if we're able to talk about it, if we're able to openly use hot water bottles in the workplace, then there's really no issue here and that breaking down that sort of stigma will be beneficial because women are able to openly do that without consequences. I guess my concern is in that interim time, the sort of blow back that women might experience if they are trying to break down those barriers and talk about it more.

I think that's also a complicated question when we think about women and girls in low-income context. There's a lot more dialogue now about we need to address menstrual stigma. But a lot of that has been focused on we'll address menstrual stigma by providing education about menstruation. I think that, yes, absolutely. When people have information and they understand that this is a normal biological process, that that's helpful. But we have a lot of research in other areas that suggests that education alone does not change social norms and doesn't change attitudes.

Yes.

So, I think equipping girls with more information is really important and useful and might help with a whole lot of things like not thinking that they're dying and understanding, "Oh, I need to treat myself in certain ways or I can manage my menstruation like this and this is normal and if this means I am potentially able to get pregnant."

And those sorts of basic pieces of information, but I don't think we know a lot about certainly changing social norms and attitudes about menstruation because we know from other sort of decades of health psychology research that education doesn't necessarily lead to behaviour change and doesn't lead to social norms change. So, I think we need to think a lot more about what kind of messaging do we want to send into communities to address this stigma.

And be careful that the kind of messages that we're sending don't have unintended consequences. So, there's an increasing narrative around menstrual hygiene. As we've talked about it, women and girls do struggle to get fit for purpose absorbance that they think are comfortable, that are going to be safe for them.

But one, there's a lot of other parts of menstrual hygiene and two, it's very easy for corporate interests, like the manufacturers and sellers of menstrual pads to then go and say, "Well, you're not hygienic unless you're using pad." And to co-opt the message of menstruation is normal and healthy. Here, use this pad to hide it, which is sort of like this contradictory message, right?

Yes.

Of, "Oh, your menstruation is totally normal and you're having it and now hide it with this pad," that's called whisper or secrets. Or you've got to spend all this money because otherwise you're not hygienic. If you're using these other types of materials that we're not maybe familiar with in the US, that you must be unhygienic and that that's inappropriate. Then you just spend all this money on our products.

Oh my gosh, so a little sidebar. I'm sure you saw the Period. End of Sentence documentary, that short documentary that was released in Netflix.

Yeah.

So many people have loved it. And I have to say I have a lot of questions about the man who we know nothing about, who was making these pads, and about what kind of menstrual management folks in these communities were doing before they're suddenly told they should be buying these pads.

Yeah.

I'm curious about if you're willing to say anything about your reaction to it.

Yeah. I mean, I often struggle with a lot of the sort of dominant or like media attention on this topic, because I should be like, "Yes, we need more attention. We need more research. We need to know more about this, maybe we'll need to know this is an issue." And then the way that that narrative is conveyed of, "Oh, look, we have these poor girls in India and they're using cloth and that's totally unacceptable. We need this man who's going to make a western pad product to save them." I mean, yeah, I've got issues with that kind of narrative.

There's a fantastic book called The Managed Body written by Professor Chris Bobel.

Chris Bobel? Yes, yes.

Yes, you should of course speak to her.

Oh, she is on my list. I've emailed her and have been trying to get her on podcast.

Oh great.

Maybe by the end of the season or starting next season I'll make that happen.

So, she's talked a lot about this sort of mixed messaging of we want to break down menstrual stigma, but we're going to do it by telling girls that they need to hide their periods more effectively, and totally agree with that. I think this narrative around pads and pads is the answer is highly problematic and also doesn't reflect the evidence which says, there's a whole lot of factors that are really important.

At the same time, I think we don't want to paternalistically say, "Well, we shouldn't be handing out pads if that's something that women want and they are having difficulties with the materials that they're currently using." So, it's a really tricky area in saying how do we reduce stigma and make it okay, but also understand that women don't want to be washing blood out of their clothes and they do want something that's easy and fit for purpose and easy to clean and maintain and should be able to have enough of it that they're not stressing about overwearing the menstrual protection that they have in because they don't know how they're going to get more of it. Yeah, we want to reduce that stress.

So, I think it's a really interesting but complicated topic.

Absolutely. So, this is a little bit of a pivot, but still, obviously, within the milieu of menstrual hygiene management. We've again sort of been dancing around this idea and you made this one point that there was the sort of one in 10 girls in Africa can't go to school because of menstrual hygiene issues. And there are these broader claims that are made in terms of, oh for instance, this western style pad that this man is giving you was going to solve all the period problems for this community or if we solve this menstrual hygiene problem in this other community girls can go to school.

Well, I feel like we've already sort of already gotten at this question about what we know about this research and that sometimes it's questionable or sometimes it's just not a strong enough evidence base to say for sure what's going on. But given the fact that maybe some of the reasons that people initially tried to get us to care about menstrual hygiene maybe aren't quite the right reasons. Why should we care about menstrual hygiene management? If it's not keeping girls from school, if it's not killing women or killing menstruators, when you talk to a funding agency and say, "This should be a funding priority, whether or not it kills people or not," what are you telling them?

Yeah. So, it's tricky. As you say, we don't know that one in 10 girls in Africa misses school due to menstruation. We do know there are a lot of narratives and a lot of qualitative studies that studies where researchers or NGOs might go out and sort of undertake these considered interviews with women and girls. And we hear that there's a lot of distress, psychosocial distress, as well as avoidance or disengagement while at school because of menstruation.

So, I think that we certainly don't have a lot of quantitative or numeric evidence on the link between different parts of difficulties managing menstruation and missing school or missing work or mental health or other sort of infection consequences. So, the evidence isn't there. That's not to say that those relationships don't exist. And I certainly think that difficulties managing menstruation do impact.

We've heard narratively on girls' education. We definitely don't have enough evidence about what kinds of interventions are effective in improving menstrual experiences and the impact that that has on potential school outcomes. There's really been very, very few studies. There are more happening at the moment, which is really positive. But at the moment, we really don't know "what works". We don't know how it works or for whom.

I think we should care about menstruation because it's a significant proportion of women's lives and if they're telling us that they're having a bad time, then we need to work out why that is and how we can improve that situation. Now, not all people that menstruate are women and not all women menstruate, but by and large, large proportions of those women menstruating are women and girls. And that means that this is easily a gender equality issue.

If we have girls who are struggling with menstruation at school and not boys, then we can think about what that means for gender parity and education, girls educational and economic outcomes, and how that's impacting on their lives. We also talked I think before about the importance of mental health, stress, trying to hide a significant part of your life and what that means for you. And that those are really important parts of women's lives, their well-being and their ability to participate fully in society is incredibly important.

And so, that's certainly what I tell funding agencies. I also say that we don't know for sure what the influence is on school attendance and other outcomes and that we need to know more about what those associations are.

Yeah, absolutely. So, you're a research associate at Johns Hopkins right now in the, did you say it was the Bloomberg School of Public Health.

The Bloomberg School of Public Health.

In the Bloomberg School of Public Health. And so, what are you working on these days?

All periods all the time.

All right. That's what I like to hear.

I do a number of different projects. One of the things I'm working on right now is actually a self-report measurement tool to capture the different parts of menstrual hygiene or different parts of what it means to manage your menstrual bleeding for women and girls. As a tool of understanding whether or not programs are changing women and girls experiences and also as a way of saying, "Well, we keep saying that there is this link between difficulties managing menstruation and school attendance. But we don't really have any good ways right now of capturing those difficulties with menstrual experience."

So, at the moment, if you wanted to look at the association between different parts of mental experience and school absenteeism, you might just look at something like is a girl using a sanitary pad or is she using cloth that she's found, and looking at the association between that and school attendance. But that doesn't really capture what we've been talking about in terms of the breadth of different even just activities that girl needs to undertake to manage her menstrual bleeding.

It's also a top-down approach, which isn't ideal because we're saying, "Well, we think that using a pad might be better. And so, we're going to compare that to using a cloth," rather than asking her something that's like, is she using the material she wants to use all of the time? Is she able to change it as often as she feels that she needs to? Does she worry about being seen? Or does she have private locations to change materials? Does she feel comfortable disposing of those materials?

So, we're working on a tool to help I guess measure women and girls' experiences have those different sort of menstrual practices and things they need to do to manage that period as a sort of way of equipping researchers and practitioners with a way of assessing those more broad, all the different parts of managing your period, not just perhaps the product that you're using to be used in sort of future research and practice.

That sounds so exciting. I cannot wait to hear more about that or see it when it's published because that sounds like an incredibly useful tool for better uncovering variation and better understanding, as you say, like what it is that people actually want from their menstrual hygiene experience. Is there any other any questions that I didn't ask that you wish I had, or anything that you really want our listeners to know that we haven't talked about yet?

I mean, I think it's fantastic that you're doing a podcast that's shedding a light on what I think is such an incredibly important topic. Generally, I want people to know that there is no one in 10 girls missing school due to their periods, but that managing menstruation is a challenge for a huge number of women and girls. And that's something that we should be thinking more about.

And that evidence is important, that understanding how is this really working for women and how we can help them is critical. But I think we've covered those topics. And I think we've talked about having that sort of humility when we approach different topics and not just assuming that we know best and that we know what women need, but actually taking the time to investigate what we're doing and whether or not it's going to have the effect that we're really looking to have.

That was beautifully put. Thank you so much Dr. Hennegan. This has really been a lovely interview and I really enjoyed learning about your work.

Great. Thank you. 

Shownotes:

In this week’s episode I interview Dr. Julie Hennegan. Dr. Julie Hennegan is a Research Associate at Johns Hopkins Bloomberg School of Public Health. She undertakes mixed-methods research exploring the design and evaluation of complex social interventions for women’s health. Julie leads multiple programs of menstrual health and hygiene research at Johns Hopkins, including a multi-country project to improve the definition and measurement of core constructs in menstrual health research.

In this episode, Dr. Hennegan and I talk about what’s called menstrual hygiene management, and how what we assume menstruators need isn’t always what they actually need. I also really appreciated what Dr. Hennegan had to say about making sure that the evidence we collect on menstruation and menstrual hygiene is good. That is, when we have the best of intentions it’s tempting to read more into what is currently not a strong evidence base. You’ll see what she means in the interview, so have a listen.

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