BackgroundOne quarter of the global population is of menstruating age, yet menstruation is shrouded in discrimination and taboos. Disability also carries stigma, so disabled people may face layers of discrimination when they are menstruating. The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity.MethodsEligible studies, gathered across all countries, were identified by conducting searches across four databases (MEDLINE, PubMed, EMBASE, Global Health) in May 2017, with alerts set on each database to highlight new titles added until April 2018. Eligible studies incorporated analyses relevant to menstruating disabled people and/or how their carers provide support during their menstrual cycle.ResultsThe 22 studies included were published since 1976; the majority after 2010 (n = 12; 55%). One study was a quasi-experiment; all others were observational. Most studies (n = 15; 68%) were from high income countries and most (n = 17; 77%) focused on people with intellectual impairments, so the review findings focus on this group and their carers. Outcomes investigated include choice and preference of menstrual product, ability to manage menstrual hygiene and coping strategies applied. Barriers faced included a lack of standardised guidance for professional carers; a lack of menstruation training, information and support provided to people with intellectual impairments and their carers; a lack of understanding of severity of symptoms experienced by people with intellectual impairments, the high cost of menstrual products and lack of appropriate options for people with physical impairments. Few interventions were found, and strategies for menstrual hygiene management applied by carers of persons with intellectual impairments include limiting the disabled person’s movements when menstruating and suppressing their menstruation.ConclusionsLittle evidence was identified on the requirements of disabled people and their carers in managing their menstruation, and only one intervention, but a range of barriers were identified. This gap in evidence is important, as the consequences of failing to meet menstrual hygiene needs of disabled people includes shame, social isolation, and even sterilisation.Systematic review registrationPROSPERO CRD42018095497.

Background Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists. Methods The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15–24, who menstruate and experience ‘a lot of difficulty’ or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11. Results Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced. Conclusion Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure ‘no one is left behind’.

BackgroundThe critical importance of safe and affordable access to water, sanitation and hygiene (WASH) is highlighted in Goal 6 of the Sustainable Development Goals, which seeks to achieve universal and equitable access for all by 2030. However, people with disabilities–who comprise 15% of the global population–frequently face difficulties meeting their WASH needs. Unmet WASH needs amongst people with disabilities may not be captured through current approaches to tracking progress towards Goal 6, which focus on household- rather than individual-level access.ObjectiveTo evaluate access to safe water, sanitation and hygiene (WASH), at the individual- and household-level, amongst people with disabilities in the Tanahun district of Nepal.MethodsA population-based survey of disability was conducted from August-October 2016 to evaluate access to improved water and sanitation facilities between households with members with disabilities (n = 198) and those without (n = 1,265) in the Tanahun district of Nepal. A nested case-control then compared individual-level access between cases aged 15 and above with disabilities (n = 192) and age-sex-location matched controls without disabilities (n = 189), using the newly developed 21-item “Quality of WASH Access” questionnaire. Multivariate regression was used to compare household- and individual-level indicators between people and households with and without disabilities. In-depth interviews with 18 people with disabilities and their caregivers was conducted to assess the acceptability and appropriateness of the “Quality of WASH Access” questionnaire.FindingsThere were no significant differences between households with and without members with disabilities in access to an improved sanitation facility or water source. However, at the individual-level, people with disabilities experienced significantly greater difficulties accessing water, sanitation and hygiene compared to people without disabilities (p<0.001 for all three scores). Amongst people with disabilities, water difficulty scores were associated with having a physical impairment and greater disability severity; sanitation difficulty scores were associated with lower socioeconomic status and physical or self-care limitations; and hygiene difficulty scores were positively associated with self-care limitations and lower socioeconomic status, and inversely associated with hearing impairments. Qualitative research found the “Quality of WASH Access” questionnaire was well understood by participants and captured many of the challenges they faced. Additional challenges not covered by the tool included: (1) time spent on WASH, (2) consistency of access, (3) sufficiency of access, and (4) dignity of access.ConclusionPeople with disabilities face substantial challenges to meeting their WASH needs, particularly in using services autonomously, consistently, hygienically, with dignity and privacy, and without pain or fear of abuse. These challenges are not captured through household-level data, and so individual-level WASH access are n...

Background: Adequate access to water, sanitation and hygiene (WASH) is imperative for health and wellbeing, yet people with disabilities, people with incontinence and people who menstruate often experience unmet WASH requirements.Methods: In 2019 we completed a mixed-methods study in two provinces of Vanuatu, (SANMA and TORBA). The study comprised 1) a population-based disability survey using the Washington Group Short-Set 2) a nested case-control study to explore associations between WASH, disability and gender, and 3) an in-depth qualitative assessment of the experiences of WASH users with additional requirements: people with and without disabilities who menstruate, or experience incontinence.Finding: 11,446 households (response rate 85%) were enrolled into the survey. All-age disability prevalence across the two provinces was 2.6% (95% Confidence Interval 2.5-2.8), increasing with age. 814 people with, and 702 people without disabilities participated in the case-control study. People with disabilities were statistically more likely to experience barriers in seven of eight intra-household indicators. WASH-related stigma, reliance on informal caregivers, and under-resourcing of WASH personnel were critical issues for people who menstruate or experience incontinence.Interpretation: People with disabilities, people with incontinence and people who menstruate in Northern Vanuatu face continued challenges in accessing safe, affordable and appropriate WASH that meets their requirements. Outputs from this study have supported progression towards gender and disabilityinclusive WASH programming in the area and highlighted the value of mixed-methods research.Funding: The research was funded by the Australian Government's Water for Women fund and donations from the Australian public.

Limited evidence exists about how to design interventions to improve access to health care for people with disabilities in low and middle-income countries (LMICs). This paper documents the development of two behaviour change interventions. Case study one outlines the design of an intervention to improve uptake of referral for ear and hearing services for children in Malawi. Case study two describes the design of an intervention to improve menstrual hygiene management for people with intellectual impairments in Nepal. Both followed existing approaches—Medical Research Council Guidance for developing and evaluating complex interventions and Behaviour Centred Design. The purpose is to demonstrate how these frameworks can be applied, to document the interventions developed, and encourage further initiatives to advance health services targeting people with disabilities. Important components of the intervention design process were: (1) systematic reviews and formative research ensure that interventions designed are relevant to current discourse, practice and context; (2) people with disabilities and their family/carers must be at the heart of the process; (3) applying the theory of change approach and testing it helps understand links between inputs and required behaviour change, as well as ensuring that the interventions are relevant to local contexts; (4) involving creative experts may lead to the development of more engaging and appealing interventions. Further evidence is needed on the effectiveness of these types of interventions for people with disabilities to ensure that no one is left behind.

Background: The Bishesta campaign is a menstrual hygiene management (MHM) intervention developed to meet the specific needs of people with intellectual impairments and their carers. It was designed and delivered in the Kavre district, Nepal. This paper explores the campaign’s feasibility and acceptability. Methods: The Bishesta campaign was delivered to ten people with an intellectual impairment and their eight carers. Data on the feasibility and acceptability of the intervention was collected through: Structured questionnaire to participants before and after the intervention, process monitoring data, post-intervention in-depth interviews with all carers, observation of people with intellectual impairments, key informant interviews with all facilitators and staff involved in the campaign, as well as ranking of the perceived appropriateness and acceptability of campaign components by carers and facilitators. Results: The Bishesta campaign was acceptable for the target groups, facilitators, and implementers. It was largely delivered with fidelity. Participants used most of the campaign components; these made the target behaviours attractive and enabled participants to carry them out with ease. There were improvements across all target behaviours. The focus of this study was feasibility, not limited-efficancy; however, indicative positive outcomes from this small sample were observed, such as an increase in young people’s levels of confidence, comfort, and autonomy during menstruation. Conclusion: Within the sample, the Bishesta campaign appears to be a feasible intervention to ensure that one of the groups most vulnerable to exclusion from MHM interventions is not left behind.

People with disabilities and as women and girls face barriers to accessing water, sanitation, and hygiene (WASH) services and facilities that fully meet their needs, especially in low- and middle-income countries. Women and girls with disabilities experience double discrimination. WASH policies should support and uphold the concepts of disability and gender inclusion, and they should also act as a guide to inform WASH programs and service delivery. Using a modified version of the EquiFrame content analysis tool, this study investigated the inclusion of 21 core concepts of human rights of people with disabilities and women and girls in 16 WASH policy documents and seven end-line program reports from Bangladesh and Cambodia. Included documents typically focused on issues of accessibility and neglected wider issues, including empowerment and support for caregivers. The rights of children and women with disabilities were scarcely focused on specifically, despite their individual needs, and there was a disconnect in the translation of certain rights from policy to practice. Qualitative research is needed with stakeholders in Bangladesh and Cambodia to investigate the inclusion and omission of core rights of people with disabilities, and women and girls, as well as the factors contributing to the translation of rights from policy to practice.

Background: Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists.Methods: The study aims to investigate barriers to MHM that people with disabilities and their carers, face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience ‘a lot of difficulty’ or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, PhotoVoice and ranking, market survey, product attribute assessment and user preference with ranking, observation of the water, sanitation and hygiene (WASH) facilities used. We analysed data thematically, using Nvivo 11.Results: Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, who overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected, for fear of being cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced.Conclusion: Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements, must be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure ‘no one is left behind’.