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Table 2 Included literature synthesised using Socio-Ecological Framework

From: Socio-cultural implications for women’s menstrual health in the Pacific Island Countries and Territories (PICTs): a scoping review

Publications (a) Country & study setting Study aim/area of enquiry Biological factors Personal factors Interpersonal factors Environmental factors Societal factors Summary of evidence
Clauson 2012 [42] Fiji
Village setting (Kadavu Island)
To understand how urbanisation affects way menstruation is treated in Fijian communities No evidence Girls aware of menstruation & menarche at pre-menarche. Supported by mothers, grandmothers & aunties. Girls learn about SRH at menarche ceremony Girls learn about menstruation from village nurses & at schools. Learning in the presence of boys in schools is challenging. Teasing results from shame and embarrassment No evidence Evidence of cultural practices. Menarche ceremonies exists but rarely observed- religious influence & living away from home. Menarche ceremonies prepare girls for womanhood. Restrictive practices not evident Menarche ceremonies used to prepare girls for womanhood. Education also reinforces pre-menarcheal learning
No evidence of restrictive practices
Fitzgerald 1990 [35] Western Samoa:
Rural village (Savai);
American Samoa: semi-urban villages, (Tutuila);
Hawaiian Samoa:
urban context, (Honolulu)
To see if culture change results in a change in menstrual experience Stoic about menstrual pain but likely to seek medical attention. Behavioural changes linked to PMS leading to decreased activity, increased sleepiness Evidence of females paying extra attention to personal hygiene & proper disposal of menstrual materials Menstruation-viewed as normal, natural & private affair for women. Public evidence of sexual behaviour for unmarried women is a cause of shame to individuals and family No evidence Concepts of menstrual pollution & taboo-not evident; casual conversation about menstruation evident between intimates; believe-pre-menarcheal coitus is pre-requisite for menarche. Belief- menstruation is evidence of sexually active status Cultural factors play significant role in the recognition, evaluation, and expression of menstrual symptoms. No evidence of menstrual pollution but increased attention to menstrual hygiene
Francois et al. 2017 [36] Fiji
School settings in Ba, Lautoka & Ra; rural, urban and peri-urban schools
To assess menstrual related challenges in schools Evidence of menstrual pain and physical symptoms-tiredness, dizziness, causing exclusion from social & sporting activities in schools. Feel unprepared to manage symptoms Lack menstruation knowledge; evidence of some knowledge gap; common knowledge source-mothers. Staining clothes cause fear, shame & lack of class concentration; staining leads to teasing Evidence of learning from school, but teaching menstruation in presence of boys’ presence leads to shame, discomfort. Repeated teasing from boys prevents girls from seeking support Evidence of adequate WASH facilities meeting standards. However, facilities lack privacy, security and sanitary pads; evidence shows challenges relating to inconsistent availability of materialsa-due to frequent cyclones & floods Cultural taboos & norms leads to lack of menstrual information. Evidence of discomfort learning about menstruation in same class with boys; cultural taboo causes discomfort for male teachers to teach menstruation topics. Some evidence of restrictive practices Girls face multiple MHH challenges due to lack of knowledge & unpreparedness; menstrual pain; fear/embarrassment of staining clothes; teasing; lack of WASH facilities. Impacts on school attendance and participation
Hugget and Natoli 2017 [37] Fiji
School settings
Explore challenges experienced by women & girls managing menstruation & whether these challenges affect participation in school, work & community engagement Many girls have pre-menarcheal awareness prior to menarche Evidence of access to education about MHH, however gaps exists-monthly cycle; disabled females often excluded access to menstrual education; generational gap exist –older women uneducated. Menstruation restricts social activities Menarche viewed-transition to womanhood; Women in workplaces & market vendors face challenges managing menstruation- single public sanitary facility. Mothers- information source but lack support. Teasing affects school attendance Evidence of high standards of WASH facilities in some schools, workplaces and public places; some WASH facilities lack soap, toilet tissues, and sanitary disposal facilities. Evidence of some facilities being locked, unclean, & requiring user fees Menstrual taboo-less strict, however levels of secrecy & discretion exist but vary according to religion and cultural background and prevailing attitudes & beliefs between Fiji’s two main ethnic groups: i-Taukei & Indo-Fijians; reaching menarche is celebrated event; strong restrictive practices exist with Indo-Fijians Women face multiple challenges impacting on MHH. These include lack knowledge and unpreparedness; restrictive practices; menstrual materials and WASH facilities
Jenkins 1994 [38] PNG
Rural & urban communities
Acquire information on men’s & women’s sources & levels of knowledge of pregnancy, childbirth, their customary beliefs & practices about reproduction, fertility control & experiences & attitudes towards childbirth No evidence Women reported having prior knowledge about menstruation before menarche Sources of information were mothers, older women, school teachers, aunties and peers. Parents control emerging sexuality of children. Sexuality information passed at a time deemed right by parents. Evidence of menarcheal ceremonies to prepare girls for womanhood Lacking safe method of disposing soiled materials Evidence of cultural beliefs and secrecy around menstruation. Taboo around menstrual blood-believed to be dirty and harmful. Restrictive food and behavioural restrictive practices exist Cultural beliefs and practices restricts pre-menarcheal awareness
Parents control flow of sexuality information. Menarche ceremonies used to teach/prepare young girls for womanhood
Mohammed and Natoli, 2017 [40] PNG,
Fiji & Solomon Island (SI)
Urban and rural settings
Describe menstruation-related attitudes and beliefs that contribute to restrictive practices in PNG, SI & Fiji; the impact of these restrictions on the lives of women and girls No evidence Evidence of lack of menstruation knowledge including pre-menarcheal knowledge. Lack of knowledge results from taboo and communication secrecy. Feeling of shame evident leads to social exclusion & impacts on young women’s education Evidence of teasing, harassment, stigma and shame about menstruation compelling girls to be more cautious and secretive. More common in PNG and Solomon Island than in Fiji. Young women leave school due to teasing and harassment including lack of proper MHM facilities Evidence of barriers to effective MHH such as poor WASH facilities. Condition worse in PNG and SI than Fiji. Womens’ ability to effectively manage menstruation is limited by poor WASH facilities Evidence of socio-cultural & religious beliefs & attitudes leads to behavioural restrictions of women. Restrictions impact on their ability to effectively manage MHH with dignity and fully participate in school, work, and broader community life. Belief that menstruation is dirty, menstruation and menstrual blood brings bad luck to men and boys, and menstruation related secrecy and shame exists. Evidence of menstruation and health-related beliefs Restrictive practices are common in PNG and SI compared to Fiji. Restrictive practices common in rural than urban areas. Some restrictive practices were perceived desirable and driven by women themselves
Mohammed and Natoli 2017 [40] PNG
Urban and rural settings
Understand how women in PNG manage menstruation & explore barriers & challenges experienced by women in managing menstruation No evidence Girls lack comprehensive knowledge of menstruation- unprepared for menarche leading to shame. Evidence of teasing by boys leading to shame and embarrassment Mothers, other female relatives, friends and female teachers are important source of information and support. Yet many lack understanding of menstruation and MHM WASH facilities in schools and workplaces rarely meet needs for managing menstruation due to lack of water supply, non-functioning toilets, unclean and poorly maintained facilities and no disposal mechanism for used soiled menstrual material. Also lack of privacy, lack of secure places for washing and personal hygiene Evidence of common beliefs and discriminatory attitudes around menstruation being dirty and unhealthy causing difficulty for women managing menstruation. Also impacts negatively on their emotional wellbeing. High level of secrecy is challenging and becomes an additional barrier to effective MHH Women face multiple challenges that influence their ability to manage menstruation hygienically. These include lack knowledge and unpreparedness; restrictive practices; menstrual materials and WASH facilities
Natoli and Huggett 2016 [39] Solomon Is. (SI)
Urban and rural settings
Understand how women in SI manage menstruation & explore barriers & challenges experienced by women in managing menstruation No evidence Evidence of girls lacking menstrual knowledge and are unprepared for menarche leading to shame & embarrassment. Teasing from boys is evident leading to embarrassment Support sources include mothers, other female relatives, friends and female teachers. However, many lack accurate and thorough understanding of menstruation and MHH Schools, workplace’s lack WASH facilities for women to manage menstruation due to lack of water supply, non-functioning toilets, unclean & poorly maintained facilities. Lack of disposal mechanism for used materials Lack of privacy, lack of secure places for washing and personal hygiene-also evident Beliefs &discriminatory attitudes around menstruation being dirty & unhealthy-evident, causing difficulty managing menstruation by women. These beliefs impacts on women’s emotional wellbeing. High level of secrecy is challenging and becomes an additional barrier to effective MHH Challenges women face are multiple. These challenges influence women’s ability to manage menstruation hygienically. Challenges include lack knowledge and unpreparedness; restrictive & discriminatory practices; menstrual materials and WASH facilities
Sniekers 2005 [34] Fiji
Villages and urban settings (Suva and Nausori):
Gain knowledge of Fijian female gender identity through studying the menarcheal ceremony No evidence Evidence of feeling scared, shamed, embarrassed-private and personal Evidence of learning from, schools teachers, mothers, aunties and grandmothers; focused learning about womanhood expectations, MHH,SRH occurs during menarcheal ceremonies No evidence Evidence of cultural secrecy & taboo of discussing sexuality; however, some evidence of menstrual blood is considered ‘mana’, harmful and sacred; menarche is celebrated event; no customs relating to restrictive practices; evidence of menarcheal ceremonies giving positive image but becoming rare Although menarcheal ceremonies are becoming uncommon, female and womanhood identity is acquired through these ceremonies. Learning for girls also takes place in schools
UNICEF 2018 [41] Kiribati
South Tarawa, Abaiang & Abemam; rural & urban school settings
Explore the extent to which menstrual hygiene practices impact girl’s educational outcomes and development in Kiribati Evidence of menstrual pain and loss of concentration from mood swings Evidence of knowledge gap relating to menstruation & reproductive health in girls, including others: school aged-boys and mothers; girls lack knowledge to track onset of periods. Lack of knowledge in boys leads to curiosity, teasing and bullying of girls in schools. Teasing and bullying causes girls’ school absenteeism, shame & embarrassment Teachers lack knowledge & awareness of MHH being part of curriculum; teachers under-resourced and undertrained to subjects and manage student’s expectations. Consequently, girls receive incomplete information regarding menstruation and SRH . Evidence that safe sanitation is far below standard for menstruating girls; girls with disability face additional barriers in managing menstruation; evidence of school absenteeism & decreased school participation due to poor WASH conditions in schools to help manage menstruation. cloths, diapers & sanitary pads used to manage menstrual blood; product choice is determined by availability & accessibility to cash . Evidence of traditional beliefs and practices in both urban and rural settings; beliefs that menstrual blood is taboo; restrictive practices; cultural beliefs causing restrictive communication amongst men and boys consequently leading to teasing and bullying of girls causing girls feeling scared & embarrassed; significance of culturally appropriate disposal method of soiled material is linked to cultural taboo around menstrual blood Young women face multiple challenges managing menstruation due to lack of knowledge, teacher’s lack of knowledge, traditional restrictive practices, shame and secrecy, poor WASH facilities, bullying and teasing. This impacts on girls’ school attendance. Young women with a disability face additional challenges
Vallely et al. 2012 [33] PNG
Sexual Health Clinic in Port Moresby
To investigate intra-vaginal practices (IVP) and vaginal microbicide acceptability, and discuss implications of findings for future HIV prevention policy and research priorities No evidence Women perceive and support the view that menstrual blood is harmful
Belief that the use of menstrual products blocks bad air from flowing inside of women’s body. Hence, women use ‘smoking & steaming’ practice to clean their birth canal
No evidence Evidence that menstruating women cleanse vulva before sex with water, soap and vaginal inserts (crushed garlic) for improved genital hygiene and vaginal soap for vagina tightening. Customary ‘steaming’ practices and menstrual blood is absorbed using fragments of materials, cloths, newspapers, baby nappies, and sanitary towels Evidence of traditional customs and norms relating to menstruation, beliefs and perceptions about menstrual blood. However some women admit having sex while menstruating Diverse range of intra-vaginal practices were reported. Customary menstrual ‘steaming’ practices; use of fragments, cloths and newspapers to absorb menstrual blood were reported. Unprotected sex during menstruation was commonly reported
  1. (a) Figure within parenthesis is reference number in reference list