In this study investigating MH perspectives and practices among AYAs in rural Haiti, a majority of AYAs reported they skipped school (with any frequency) due to their menses. Further, more than half worried that something or someone would harm them while they were changing their menstrual materials at home and at school. These findings reveal potential opportunities to improve school attendance during menses, as well as access to MH materials and safe places for changing of menstrual materials for AYAs in rural Haiti.
According to the MPNS-36, more than two-thirds of participants reported unmet MH needs, with the most pressing unmet needs related to school environment (i.e. having a clean and satisfactory place to change materials), menstrual material reliability (i.e. leakage or instability of materials), and change insecurity (i.e. fear of being harmed while changing materials at home and at school). In the MPNS-36 validation study conducted among schoolgirls in Uganda, rates of unmet MH needs were similar to our findings, however, the highest proportion of unmet needs was regarding material and home environment needs (84%) . In our study population, the prevalence of menstruation-related school absenteeism in rural Haiti was higher compared with similar studies among AYAs in rural settings in other LMICs (i.e., 28%  and 40%  in Ghana, and 61%  in Ethiopia). Some past studies assessed school absenteeism using a binary response (“yes” or “no”) while we used Likert-scale responses (never, sometimes, often, always) which may partially account for this difference [19,20,21,22,23]. As most schools in Haiti do not have toilets or running water, it is likely that concerns about unmet MH needs related to school environment and school attendance may be partially driven by lack of adequate WASH facilities . While our study did not investigate explanatory factors, studies from other LMICs have demonstrated increased risk of MH-related absenteeism in populations with higher levels of perceived MH stigma, rural settings, lower SES, and cultural restrictions during mensturation (including exclusion from school, as well as religious events, family homes, and public sanitation facilities) [11, 16, 17, 19, 21,22,23, 37]. School absenteeism could also be affected by menstrual discomfort, as well as cultural shame or stigma. Thus, the high rate of school absenteeism observed in our study may be partially driven by these factors. Additionally, our study took place shortly after the earthquake that occurred in Southern Haiti on August 14, 2021, which resulted in damage or complete destruction of many schools. While some temporary learning structures (e.g., tents) have been erected, many students still do not have access to permanent school facilities. This may have impacted our study findings regarding concerns about school environment and menstruation related school absenteeism . Further study into underlying drivers (e.g., menstrual discomfort, cultural stigma), as well as the impact of disasters on MH concerns about school environment and attendance is needed to inform efforts to offset MH-related school absenteeism among AYAs in Haiti. We found a high proportion of our respondents reported material reliability concerns. Among those who reponded to the questions about specific MH product use, most reported using disposable sanitary pads, or cloths/towels, which may be more prone to leakage or not staying securely in place. Future work is needed assess MH product access in Haiti and potentially develop interventions to offer higher quality MH products to young women in rural Haiti. Additionally, in our study, those who reported no religion were more likely to have a low score, indicating unmet MH needs. As numerous non-profit and humanitarian aid organizations, some of which are religiously-affiliated, offer housing, food and healthcare services in Haiti, this finding may be partially driven by women affiliated with a religion accessing resources from religiously affiliated organizations . Further study is needed to better understand the association between MH resources and affiliation with a religion.
Safe spaces in home and schools for MH become more scarce in post-disaster and humanitarian settings, especially when these events lead to internally displaced people [39, 40]. Without a private and secure (e.g., lockable) space to manage menses, women are at increased risk of GBV [41,42,43]. More than half of our participants reported they sometimes, often, or always worried that something (e.g., animals, unsafe structures) or someone would harm them while they were changing their menstrual materials at home. As noted above, our study took place shortly after an earthquake (August 2021), which may have impacted our study participant’s reported safety concerns. Following the earthquake, approximately 13,000 houses were partially or completely destroyed . Recent reports reveal that one year later, thousands of displaced families are still living in camps or under tarps and only 38 of 1250 damaged or destroyed schools have been rebuilt [45, 46]. Thus, further earthquake recovery and rebuilding needs remain which may continue to affect the security of AYAs in southern Haiti. In our study, participants who reported living in a tent were more likely to report safety concerns at home while changing their menstrual materials, compared to those living in a house. A previous study using the MPNS-36 among young Venezuelan migrant women at the Brazilian border found that 76% of women were afraid to be harmed by someone while changing their menstrual materials and 82% were afraid to be harmed by an animal or insect . Displaced women are vulnerable to GBV due to increased poverty and reduced community networks . A study on WASH-related needs of refugee women and girls, including Haitians, identified communal latrines, along with bathing in the bush, as dangerous, particularly at nighttime . It is possible that concerns about being seen while changing or washing materials are related to the fear and threat of violence. Further study is needed to understand the underlying factors related to these MH safety concerns and risk for GBV at home and schools among young women in Haiti, particularly during and after natural disasters or political unrest.
Our findings should be viewed in light of these limitations. Data on those ineligible or who declined to participate was not collected, thus we were unable to assess for differences between those who participated and those who declined. We also added four additional questions in the midst of data collection which were only answered by participants at site 2. We enrolled a convenience sample of AYAs, thus there is risk for sampling bias and that our sample may not adequately be representative of the larger AYA population in these areas. While our sample was slightly smaller than similar studies, we did enroll across two rural geographic areas, which strengthens generalizability, particularly among other rural LMICs populations. Additionally, our study population demographics are comparable to population level data on adolescents and young adults living in Haiti, with similar rates of school attendance and educational attainment . Due to the sensitivity of the topic, there is also risk for potential social desirability bias leading to inaccurate reporting. We attempted to mitigate this by conducting data collection privately and engaging trusted community members to assist with data collection. As our study included only close-ended questions, MH perspectives could be further explored using qualitative methods in the future. We used the validated MPNS-36 to assess unmet MH needs, however, it is still a relatively new MH assessment tool and normative data to date is lacking. Additionally, the MPNS-36 did not specifically assess school absenteeism, thus we added a survey question adapted from other past MH studies .