MHH intervention uptake
Of the 1732 eligible participants who sought services at the CHIEDZA centres between April and July 2019, 1414 (81.6%) took up the MHH intervention at their first visit. There was no evidence of a difference of uptake between the four sites. There was strong evidence for a difference in uptake by age group with 690/816 (84.6%) of 16–19 year olds compared to 724/916 (79.0%) of 20–24 year olds accessing the MHH package (p = 0.003).
From the qualitative data, key themes related to factors that influenced uptake of the MHH intervention were access to free menstrual products and analgesics, youth-friendly intervention delivery, and access to MHH information.
Access to free menstrual products and analgesics
Almost all participants, particularly younger women, cited the MHH intervention as the reason behind their initial CHIEDZA visit:
“I personally came here with an intention to get pads and when I entered into the CHIEDZA booth, I saw a very friendly service provider and felt comfortable and free to talk” (FGD, 16–19 years old).
A key motivating factor for the observed high uptake was the provision of free reusable menstrual products, particularly reusable pads. Most participants reported having to use old socks or cotton wool in the absence of the menstrual product they would prefer to use or were able to afford before the economic downturn in Zimbabwe:
“sometimes I would also use cloths when I didn’t have enough pads to last my period” (FGD, 20–24 years old).
Almost all participants reported that they were “grateful” and “happy” that the intervention provided them with a choice of menstrual products which they could not afford and did not have access to before. MHH intervention team members also reported that the free products were “the most important hook” for young women that accessed the CHIEDZA services:
“…those who are coming in for menstrual hygiene, they are going out and inviting others for menstrual hygiene. They are only telling them that if you go to the community you can get pads, you can get a cup or something. They are not really raving about other services but it’s all about menstrual hygiene… the communities love the products we have” (FGD, Nurse).
Some participants reported experiencing pain during their menstrual periods and cited access to monthly analgesics as an additional reason for taking up the MHH intervention.
Almost all participants chose to take up the MHH intervention. Of those that did not, most only declined uptake because their menstrual product of choice was unavailable on the day of their visit.
Youth-friendly intervention delivery and access to MHH information
Participants had learned about the MHH intervention in CHIEDZA through community mobilization efforts facilitated by the intervention team:
“…we were on our way from clinic and we were told to go to the community hall to get some pads” (FGD, 20–24 years old).
Once at CHIEDZA, participants reported being “treated well” and many found the service providers “friendly” and “helpful”. MHH intervention uptake was both a function of the provision of needed menstrual products and youth-friendly service provision facilitated by the delivery team. Participants highlighted how the intervention staff, unlike their parents or teachers, provided much needed access to MHH information in a safe, non-judgemental environment and in a way in which resonated with them:
“I think this is a good programme because it helps us. Some children might have questions but they are not able to ask their parent, they might not be open to their parents but CHIEDZA, you are free to ask and say things you want” (FGD, 16–19 years old).
Many participants described how their only conversations about menstruation began and ended at menarche and were limited to menstrual product use and basic hygiene guidance. The MHH intervention provided young women an avenue to learn more about menstrual health from trained staff and to talk through their MHH-related concerns and anxieties in a safe space:
“When I entered into the booth, I saw a very friendly service provider and felt comfortable and free to talk and I was able to express my feelings and to openly seek the help I needed, and I was assisted there. Getting pads was now an extra benefit” (FGD, 16–19 years old).
Participants highlighted the MHH-related education sessions with the intervention staff. These sessions gave participants an opportunity to feel the menstrual products, to observe menstrual product use demonstrations, and to openly discuss myths and taboos around menstruation in private consultation. All the intervention team members reported that the MHH component of CHIEDZA was received with “gratefulness” and was the “most popular” service.
Overall, both the provision of free menstrual products and youth-friendly service provision were highlighted as key facilitators to intervention uptake. However, older participants seemed to be more motivated by the former rather than the latter as most of them had children with them or household responsibilities to get back to and thus did not have the time to engage in the MHH-related education sessions or other youth-friendly activities within CHIEDZA.
Menstrual product choice among participants
Of the 1414 participants who took up the MHH intervention, 1244 (88.0%) participants chose to receive the reusable pads and the remaining 170 (12.0%) chose a menstrual cup on their first visit. There was strong evidence of a difference of product choice by age, with 50/690 (7.2%) of 16–19 year olds to take up the MHH intervention choosing the menstrual cup versus 120/724 (16.6%) of 20–24 year olds (p < 0.001) (Fig. 4). The qualitative data with clients and the intervention team highlighted key themes related to factors that influenced product choice: barriers and facilitators to the uptake of menstrual cups; and barriers and facilitators to the uptake of reusable pads.
Barriers to the uptake of menstrual cups
Sociocultural norms negatively influenced both the delivery and the uptake of the menstrual cup among participants. Participants reported that they and their caregivers in the community were hesitant about inserting the cup into their vagina. Most feared that the cup would “take their virginity”. Some feared that the “big” cup would be too difficult or painful to insert. Others thought the cups were stiff and hard and feared that the cup would stretch out their vagina making them undesirable for men to have sex with. The FGD with the intervention team members also highlighted these fears, and this affected their ability to promote cup uptake, with many explaining their struggles with delivering clear messaging to allay these concerns:
“I think it’s also an issue of needing to look at our cultural values. It’s about what are we told from childhood about virginity and inserting such big things. So that issue is a concern and how would you tackle it if you want to introduce a cup” (FGD, Community health worker).
Participants mentioned that the intervention team appeared reluctant to talk about and distribute the cup, and some expressed that they would have been willing to trying the cup if it had been talked about during service delivery:
“I just heard someone saying cup, but I did not know which cup she was referring to… I got pads instead of cup, and then I was like a cup? I did not get it, I thought she is talking about a cup of tea. I honestly thought that the CHIEDZA people had been unfair, and I wanted to go back and to get a cup” (FGD, 20–24 years old).
Facilitators promoting the uptake of menstrual cups
The main factors that facilitated menstrual cup uptake included anecdotal evidence of menstrual pain relief and the prevention of leakage. Some participants chose the cup over the reusable pad as it could be cleaned and dried discreetly. Even though most participants chose the reusable pads, many raised concerns over their need to “keep [their menstruation] a secret”, and challenges in washing and drying their pads outside where other family members and neighbours could see.
The majority of participants gave negative accounts of their menstrual experiences and often described menstrual blood as “dirty” or “impure”. Many spoke about being restricted from housework, social or religious gatherings or sports while others expressed fears of leaking or “spoiling” their clothes leading to being “teased” by boys or chastised by other females during their menstrual periods. Informed by these negative perceptions and experiences of menstruation, some participants chose the menstrual cup over the reusable pads as they felt it was less likely to leak:
“The time for menstruation is so annoying because you will be anxious and you will be afraid of spoiling your clothes, you may not feel comfortable with a pad, so I decided to try a cup” (IDI, 20–24 years old).
Others that chose to take up the menstrual cup also cited “pain relief” as reason for uptake:
“[Other participants] told me that period cup heals period pains slowly. If you continue to use it you end up not having period pains” (FGD, 20–24 years old).
Limited access to water in the communities and seasonal rains also informed product choice. Some of the participants who opted for the cup cited the fact that it did not require much water to wash or time to dry as reusable pads as the reason for their choice:
“the cup is very smart, and you don’t need to do much washing, but you just remove it and empty it” (IDI, 20–24 years old).
Barriers and facilitators promoting the uptake of reusable pads
The main facilitators included peer influence (particularly for participant’s aged 16–19 year olds) and the similarity between reusable pads and disposable pads. Participants noted that the reusable pads were most similar to disposable pads they had used before and therefore the less “scary” than the cup. Many of the participants, particularly those aged 16–19 years old, were encouraged to visit CHIEDZA by a classmate that had previously visited the intervention site:
“We were in class and Rashna brought her pads and started to show us, ‘see what they look like, and see what they look like!’ So I said, ‘Where did you get them?' and she said 'I got them from the community centre, on Tuesdays.’ Today is my second time coming here, when I came for the first time, I was given pads” (FGD, 16–19 years old).
Overall, the few barriers to reusable pads uptake seemed to be linked to the environmental factors that facilitated menstrual cup uptake.