Measuring menstrual hygiene in high-income countries: A scoping review

Abstract

Background:

Despite growing recognition of menstrual hygiene management (MHM) challenges in high-income countries (HICs), validated measurement tools specific to the context and experiences of these populations are lacking, with most tools being developed in low- and middle-income countries. The lack of validated instruments makes it difficult to examine the extent of menstrual product insecurity, period poverty, and menstrual hygiene in HICs, and limits researchers’ ability to evaluate trends over time.

Objective:

To summarize menstrual hygiene measurement tools developed and/or used in HICs, as well as the domains covered and psychometric properties of these tools, such as validity and reliability.

Eligibility criteria:

Studies conducted in HICs, discuss MHM, and employ a quantitative or mixed-methods design.

Source of evidence:

Published studies were sourced from OVID Medline, Scopus, and CINAHL Plus using standardized search strategies.

Charting methods:

Data from the included studies were charted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).

Results:

Forty-five studies conducted in HICs between 1996 and 2024 met the inclusion criteria. Most were quantitative (n = 38), and the majority were conducted in the United States (n = 26). Across studies, 741 MHM measurement items were identified with menstrual product insecurity, psychosocial concerns, absenteeism, and menstruation-related consequences, and water, sanitation, and hygiene factors. Twelve studies reported psychometric properties; however, only five instruments were fully validated, and none comprehensively measured “period poverty.” Items assessing product insecurity and absenteeism varied widely in wording, response options, and domains covered, limiting comparability across studies.

Conclusion:

Despite growing research and policy attention, HICs lack standardized, validated tools to measure menstrual product insecurity, period poverty, and related outcomes. To advance menstrual equity, track progress, and improve menstrual health outcomes, there is an urgent need for reliable and validated measurement tools that support surveillance, policy evaluation, and intervention efforts.

Keywords

menstrual health menstrual hygiene management period poverty scoping review questionnaire survey instruments

Introduction

Menstrual hygiene management (MHM) encompasses access to clean menstrual products, adequate sanitation facilities, knowledge, privacy, and the ability to manage menstruation with dignity. While MHM has largely been studied within low- and middle-income countries (LMICs),^1,2 there is increasing recognition that menstrual health challenges also persist in high-income countries (HICs), albeit in somewhat different forms.^3–5 Issues such as period poverty, menstrual stigma, inadequate menstrual education, and lack of access to appropriate infrastructure (e.g., trash bins, private toilets, soap, and water ) affect people who menstruate across income levels and social classes, even in wealthier nations.^6,7

Period poverty in HICs, including the United States, Europe, and Australia, has been associated with school and work absenteeism, poor mental health, and shame among adolescents and adults.^3,8–10 Moreover, systemic barriers such as housing insecurity, racial inequality, and restrictive gender norms further exacerbate menstrual inequities.^11,12 Despite growing advocacy and policy responses, such as tax exemptions and free product provision,^13,14 measurement of menstrual health outcomes remains inconsistent and fragmented.

Most validated tools for measuring MHM were developed in LMICs and tend to emphasize infrastructure and supply limitations,¹⁵ which may not fully capture the sociocultural and policy dimensions relevant to HICs. Furthermore, no systematic synthesis currently exists to evaluate whether existing tools in HICs appropriately measure domains like accessibility, choice, acceptability, and self-efficacy around period products and MHM.

Therefore, this review aimed to identify and explore the MHM measurement tools used in high-income contexts. By examining the domains, psychometric properties and relevance to diverse populations of these constructs, the findings will inform future research, policy, and advocacy efforts aimed at achieving menstrual equity across socioeconomically and culturally diverse settings in HICs. While the field is increasingly adopting the more holistic term Menstrual Health and Hygiene (MHH), we use MHM here for consistency with the terminology used in the literature and measures analyzed, while acknowledging this broader shift.

Objective

To identify and describe MHM measurement tools developed or used in HICs. In addition, we aim to explore the domains covered and the psychometric properties (validity and reliability) of these tools.

Methods

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines,¹⁶ and the protocol is registered with PROSPERO with registration number CRD420251016814.¹⁷

Published studies were identified from three databases: OVID Medline, Scopus, and CINAHL Plus. We included these databases because our focus was on public health and sanitation-oriented measurement tools rather than psychological constructs. The databases were searched for studies published before February 2025. Review of the literature and selection of eligible articles from the databases was completed from September 2024 to February 2025. A university librarian was consulted for assistance with the initial search. Keywords used included terms related to “menstrual health,” “menstrual hygiene,” “water, sanitation, and hygiene,” “period poverty,” “mixed methods,” “quantitative,” “survey,” and “questionnaire” (Table 1). There were no date limits on the search. Please see the Supplemental Material for the full electronic search strategy for the Ovid Medline database.

Table 1.

Search strategy.

Concept number	Concepts	Search terms
1	Menstruation	Menstruation OR menses OR menstruation* OR period poverty
2	Hygiene	Hygiene OR sanitation OR water OR (hygien* or sanita* or water)
3	Methodology	Mixed method OR RedCap OR Qualtrics OR EPInfo OR survey* OR questionnaire*

The eligibility criteria for screening were (1) conducted in HICs as determined by the World Bank, (2) studies conducted in both HICs and LMICs (only the HIC-specific information was extracted), (3) quantitative or mixed-method study, and (4) discussed menstrual health and hygiene management. The exclusion criteria were (1) studies conducted exclusively in LMICs, (2) studies that do not involve a specific MHM measurement tool, (3) review and conference papers, and (4) articles published in a language other than English.

The studies identified using the search strategy were imported into EndNote, and duplicate items were removed. Titles and abstracts of identified citations were screened for eligibility criteria by two co-authors (JA and EF). Disagreements between the two reviewers were resolved by a third reviewer. Once the studies that met the eligibility criteria were identified, the full texts were reviewed by three co-authors (JA, EF, and MTT). Data from the included studies were explored by these co-authors using a standard data charting form. The standard data charting from was developed by the authors for this review and includes data on location, participants, number of participants, study design, menstrual hygiene construct/dimension, and assessment tool. The senior author (ASK) reviewed all tabulated data to resolve discrepancies and verify the accuracy of data reporting in alignment with the findings from the included studies. Information extracted about each article included geographic location of the study, setting, participant characteristics and sample size, study design, assessment tool/method, menstrual hygiene constructs and psychometric properties, and precise survey questions (Table 2). If the articles did not include the full questionnaire or exact survey items, then item wording was surmised from what was reported in the methods and results sections.

Table 2.

Characteristics of included studies.

First author and publication year	Location (city, state, country)	Setting (school, general population)	Participants (e.g., school-age, adults etc.)	Sample size	Menstrual hygiene construct/dimension (absenteeism, menstrual product insecurity, product source)
Alenizy, 2024	Saudi Arabia	General population	Women, 11 years and older (including those who are menopausal)	3471	N/A
Ali, 2024	Sharjah, United Arab Emirates	School	4th–12th grade private school students, 8–17 years old	390	N/A
AlMutairi, 2021	Buraidah city, Saudi Arabia	School	Intermediate girls, 12–16 years old	258	Absenteeism
Bano, 2015	Hail, Saudi Arabia	College	18–40 years old	120	Absenteeism
Boden, 2023	St. Louis, Missouri, USA	Homeless service agencies	Women experiencing homelessness, 18 years and older	30	Menstrual product insecurity
Calderon-Villarreal, 2024	Tijuana, Mexico San Diego, California	Street outreach and mobile vans	People who inject drugs, 18 years and older	125	N/A
Cardoso, 2021	USA	General population	College attending women (undergrad), 18–24 years old	515	Menstrual product insecurity
Choi, 2021	South Korea	Korean Nurses Association	Korean female nurses, 20–45 years old	8658	Absenteeism, menstrual product insecurity
Coombe, 2022	Australia	General population	18 years and older	410	Menstrual product insecurity
Cotropia, 2019	USA	General population	Women ages 18–25 years old	93	Absenteeism, menstrual product insecurity, product source
Czerwinski, 1996	Southeast Texas, USA	Family planning clinic	Clients, 18 years and older	193	N/A
Czerwinski, 2000	California, USA	Professional home economics organization	Female members of organization, 18 years and older	713	N/A
Czerwinski, 2001	USA	Military	Deployed after 1989, U.S. Air Force, Army, Navy, Marines	880	Absenteeism
Darivemula, 2023	Kansas City, Missouri, USA	Jails	Women leaving Kansas City jails	235	Absenteeism, menstrual product insecurity
Dube, 2024	Ras Al-Khaimah, United Arab Emirates	RAK Medical and Health Sciences University	Female students and faculty of Medical, Dental, Pharmacy, and Nursing colleges	253	Absenteeism
Feeley, 2024	Toledo, Ohio, USA	School	Middle and high school students, 9–19 years old	408	Absenteeism, menstrual product insecurity
Hunter, 2022	USA	General population	18–49 years old	1037	Absenteeism, menstrual product insecurity
Huseth-Zosel, 2022	Midwest USA	School	Teachers of grades 5–12	209	Absenteeism, menstrual product insecurity, product source
Jones, 2001	UK	School	Head teachers	282	Menstrual product insecurity, product source
Kim, 2020	Seoul and Incheon, South Korea	School	College students	383	Absenteeism
Knox, 2023	Glasgow, Scotland	Glasgow Royal Infirmary (large, urban teaching hospital)	Hospital staff	Cycle 0 (initial survey among specialist assessment and treatment area staff): N = 22 Cycle 1 (hospital-wide survey): N = 968 Cycle 2 (staff on downstream medical wards): N = 46 Cycle 3 (healthcare staffs): N = 71	Menstrual product insecurity
Lukindo, 2022	Nova Scotia, Canada	General population	Younger than18 years old	420	Absenteeism, menstrual product insecurity, product source
Maroko, 2021	Manhattan, New York, USA	Public restrooms	N/A	Audit of 25 public toilets	N/A
Massengale, 2024	USA	Period supply bank	Workers at partner agency of period supply bank	Baseline—64 Follow up—39	Absenteeism, menstrual product insecurity, product source
Medina-Perucha, 2020	Barcelona, Spain	School	Young people who menstruate, 11–16 years	N/A (protocol)	Absenteeism, menstrual product insecurity
Medina-Perucha, 2023	Spain	General population	18–55 years old	22,823	Absenteeism, menstrual product insecurity
Munro, 2022	Sydney, Australia	University	16–46 years old	410	Absenteeism, menstrual product insecurity
Nakao, 2023	Fukuoka Prefecture, Japan	School	High school female students	198	Absenteeism, menstrual product insecurity
Obionu, 2024	Kansas, Illinois and Missouri, USA	Food pantries	Pantry users, 18 years and older	4924	Menstrual product insecurity
Palovick, 2024	USA	General population	Adults of reproductive age, 18–49 years old	992 participants—2018 1037 participants—2021	Absenteeism, menstrual product insecurity
Parent, 2022	Reims, France	University Hospital Center	Gynecology-Obstretrics department patients, 18–50 years old	1153	Menstrual product insecurity
Parsons, 2024	Australia	Emergency management agencies	Staff or volunteer of an emergency services agency in a role that requires deployment operationally, 18 years and older	287	Absenteeism
Phillips, 2021	Northeastern USA	Military	Women assigned to Air Force Security Forces unit, 18–49 years old	16	Menstrual product insecurity
Ramsay, 2023	Victoria, Australia	General population	15–29 years old	596	N/A
Ricker, 2021	USA	Military	Female military officers	108	N/A
Sebert-Kuhlmann, 2019	St. Louis, Missouri, USA	Not-for-profit community service organizations	Low-income women, 18 years and older	183	Menstrual product insecurity
Sebert-Kuhlmann, 2020	St. Louis, Missouri, USA	School	High school students	58	Absenteeism, menstrual product insecurity, product source
Sebert-Kuhlmann, 2023	Missouri, USA	School	School nurses	976	Absenteeism, menstrual product insecurity, product source
Sebert-Kuhlmann, 2024	St. Louis, Missouri, USA	School	High school students	119	Absenteeism, menstrual product insecurity
Sommer, 2022	USA	General population	Female U.S. residents, 18 years and older	1496	Menstrual product insecurity
Suleman, 2024	Chicago, Illinois, USA	University	Students, 18 years and older	118	Absenteeism, menstrual product insecurity, product source
Trant, 2022	USA	Academic health center	Pediatric providers and patients aged 13–24 years old	69—providers 109—patients	Absenteeism, menstrual product insecurity, product source
Trant, 2023	New Haven, Connecticut, USA	Academic health center	OB/GYN medical staff and patients aged 18 years and older	54 -medical staff 186—patients	Absenteeism, menstrual product insecurity
Trego, 2010	USA	Military	Women in U.S. Army	278	Menstrual product insecurity
Turker, 2023	Turkiye	General population	Adolescent girls and young women with and without cerebral palsy, 10–30 years old	75—with CP 89—no CP	N/A

Once the characteristics of the included studies were documented, article information was organized into an Excel spreadsheet to synthesize individual questionnaire items within MHM-related constructs. This process was done by one reviewer (JA) and verified by a second reviewer (EF) to ensure agreement. Any questions or discrepancies were resolved in discussion with the other co-authors (MTT and ASK). Items related to menstrual product insecurity, absenteeism, and product source constructs were further examined to understand and describe the characteristics of questions.

Results

The initial search yielded 2108 citations from OVID Medline (n = 620), Scopus (n = 1165), and CINAHL Plus (n = 323). A total of 45 studies met our inclusion criteria and were included in the final analysis (Figure 1). The included studies were published between 1996 and 2024 (Table 2).

Of the 45 articles included, 38 were quantitative^{3–5,8,18–51} and 7 used a mixed-methods approach.^52–58 Most of the studies used questionnaires (n = 44),^{3–5,8,18–52,54–58} while one was an audit.⁵³ The majority of the included studies were conducted in the United States (n = 26).^{3–5,8,27,30–34,36–38,42–44,46–50,52,53,56–58} Four of the included articles were from Australia,^20,29,45,55 with two each from Spain,^19,54 South Korea,^28,40 and the United Arab Emirates,^25,35 three from Saudi Arabia,^23,24,26 and one each from Canada,¹⁸ Japan,²¹ France,²² Turkey,⁵¹ United Kingdom,³⁹ and Scotland.⁴¹ Studies were conducted across various settings, including healthcare (5),^{22,31,41,57,58} schools (n = 15, including K (Kindergarten)–12 and college),^{3,20,21,23,25,26,35,36,38–40,47–49,54} community organizations (n = 4),^32,42,43,52 corrections facilities (n = 1),³⁴ military bases (n = 3),^46,55,56 and among the general population (n = 17).^{4,5,8,18,19,24,27–30,33,37,44,45,50,51,53} A majority of the studies included adult participants (n = 32),^{4,5,8,19,22,26–35,37–44,46,47,49,50,52,53,55–57} followed by nine studies with youth participants aged between 8 and 24 years old, as defined by the study,^{3,18,21,23,25,36,48,54,58} and 4 studies that included both youth and adults.^20,24,45,51

Within the 45 studies, we identified 741 total items related to menstrual hygiene. These items reflected constructs related to knowledge/education (n = 92),^{3,19,20,22–26,35,36,41,45,47–49,54,55,57,58} psychosocial concerns (n = 98),^{5,18–22,24,26,28,30,35,36,41,42,45–47,49,50,54,55,57,58} absenteeism and the impact of menstruation on productivity and social engagement (n = 65),^{3,18–21,23,26,28,30,33–38,40,42,44,47–49,54,55,57,58} menstrual products used/preferred (n = 58),^{4,5,20–23,25–28,31–35,40,42,45,47,49,51,54,55,57,58} menstrual symptoms (n = 53),^{20,21,23,24,28,46,49–52,54,55} menstrual product insecurity (n = 100),^{3–5,8,18–22,28–30,34,36–39,41–44,47–50,52,54,56–58} menstruation-related water, sanitation, and hygiene (WASH; (n = 139),^{20,22–27,31–35,39,40,46,49–51,53–55} menstrual status/characteristics (n = 50),^{4,20,22–26,28,30,35,36,48,49,51,54,55,57,58} menstrual product source (n = 18),^{3,18,30,38,39,42,47,49,54,57,58} menstrual suppression (n = 22),^{21,24,26,46,50,51,55–58} sexual activity during menstruation (n = 2),⁵⁸ product costs (n = 4),^18,49,57,58 reproductive health/menstrual disorders (n = 11),^{20,26,30,35,47,55,57,58} teachers as proxy (n = 5), cultural practices during menstruation (n = 8),²⁴ experiences of menstruation in the workplace (n = 13),⁵⁵ and miscellaneous (n = 3; Table 3).^39,42

Table 3.

Distribution of menstrual hygiene management related item constructs (n = 741 items).

Construct category	Description of construct	Number of items
Knowledge/education	Menstrual knowledge, educational preparedness	92
Psychosocial concerns	Shame, stigma, anxiety, perceptions	98
Absenteeism and social/work impacts	Missing school, work, social activities	65
Menstrual products used/preferred	Product type, preferences, practices	58
Menstrual symptoms	Pain, cramping, physical symptoms	53
Menstrual product insecurity	Affordability, accessibility, availability, coping strategies	100
Menstruation-related WASH	Access to water, sanitation, hygiene facilities	139
Menstrual status/characteristics	Cycle regularity, flow, onset	50
Product source	Where/how products obtained	18
Menstrual suppression	Practices, attitudes	22
Sexual activity during menstruation	Behaviors during menstruation	2
Product costs	Cost-related questions	4
Reproductive health/menstrual disorders	Polycystic ovary syndrome (PCOS), endometriosis, irregularities	11
Teachers as proxy respondents	Teacher-reported items	5
Cultural practices	Traditions, restrictions	8
Workplace experiences	Menstruation in employment settings	13
Miscellaneous	Other unclassified items	3
Total		741

Psychometric properties

Twelve of the included articles discussed the psychometric properties of measurement scales. Of which, three studies used a previously validated scale about attitudes among the military sub-population, Military Women’s Attitudes Toward Menstruation and Menstrual Suppression (MWATMS-9).^46,50,56 Another study also evaluated menstrual health and hygiene among deployed women by developing and validating the Deployed Female Health Practice Questionnaire.³³ A study by Calderon-Villarreal et al. developed a validated instrument to measure menstrual health-related WASH domains among people who inject drugs (MH WASH Domain Scale-12). To examine the instrument’s ability to accurately measure domains and its overall performance, the study conducted validity (content and face validity) and reliability assessments. The Cronbach’s alpha of the 12 items tool was 0.81.²⁷ Another study used a combination of validated and reliable instruments, including the Menstruation Symptom Questionnaire and Genital Hygiene Behavior Scale among women and girls with cerebral palsy.⁵¹ Other studies also reported evaluating content validity ^24,40 and face validity.²⁴ Additionally, one study used a questionnaire adapted from a previously validated questionnaire developed in Western Ethiopia.²³ Two studies described the development and use of the Feminine Hygiene Questionnaire, evaluating the instrument’s content validity and internal consistency.^31,32 Though some of the included studies used or adapted previously validated measurement tools, none of the validated instruments measured period poverty or menstrual product insecurity.

Item constructs

Items within the menstrual product insecurity, absenteeism/consequences, and product source constructs were further assessed based on the characteristics of the item and response options. These constructs are not entirely mutually exclusive as some items captured information across and within multiple constructs. For example, an item asking about menstrual product insecurity may focus on the affordability and availability of products as well as inquire about the financial impact of product insecurity (consequence). The item construct groups are shown in Table 3.

Menstrual product insecurity

Items within the menstrual product insecurity construct reflected period poverty (if the item specifically included the term “period poverty”), reason for insecurity (i.e., affordability, availability, accessibility, management), insecurity experiences by setting, financial impact (i.e., trade-offs, reliance on outside sources for products, limited choices, unmet need), strategies to cope with product insecurity (i.e., overuse, substitution, reuse, inability to change when needed), downstream impacts of insecurity (i.e., health, psychological), and frequency of insecurity (i.e., ever/lifetime, specific period of time, COVID-19, estimation of frequency of experiencing insecurity). These questions were asked in a variety of ways, including open-ended, yes/no, and multiple-choice response options. Furthermore, most of these items were asked of respondents themselves, thus capturing self-reported data. A few, however, were measured via proxy, for example, teachers or school nurses reporting students’ needs.

Of the 100 items within the menstrual product insecurity construct, 3 items explicitly used the term “period poverty” in the question wording.^4,37,44 Ninety-two items captured reasons for menstrual product insecurity, covering everything from affordability to accessibility, and availability to management.^{3–5,8,18–22,28–30,34,36–39,41–44,47–50,52,54,56–58} Affordability related to the financial costs of purchasing menstrual products, while accessibility related to whether products were physically obtainable by the respondent. Availability related to whether products were present and available to be obtained, and management related to respondents’ ability to manage menstruation and personal hygiene during menstruation through access to adequate WASH facilities. Within menstrual product insecurity, 39 items examined affordability,^{3–5,8,18–20,30,36,37,44,47–49,54,57,58} 19 items explored accessibility,^{18,20,21,29,30,34,36–38,41,44,47,52,54} 19 examined availability,^{5,18–20,34,36,38,39,41–43,47,54} and 15 explored management.^{5,19,22,28,30,42,47,50,52,54,56}

Menstrual product insecurity items were used in questionnaires across a variety of settings and populations. Eighteen items examined menstrual product insecurity experienced at school,^{3,18,20,30,38,39,47,48,54} five at work,^28,41,50,56 seven in corrections facilities,³⁴ one at a food pantry,⁴³ and two at community organizations.⁴²

Next, items were described by the financial implications of menstrual product insecurity. Topics covered within financial implications included making trade-offs between period products and other essential needs, reliance on outside sources to obtain menstrual products, limitations in product choice, and unmet need for menstrual products. Of the 30 items examining financial impact,^{3–5,8,18–20,22,29,30,34,37,38,42–44,48,49,54,57,58} 3 investigated trade-offs,^34,37,44 13 examined reliance on outside sources,^{8,18,20,30,37,38,42–44,49} 8 examined limitations in product choice (i.e., difficulty affording usual or preferred product, switching to alternative product brands/generics due to financial pressures),^{5,19,22,29,54} and six examined unmet product needs (i.e., went without menstrual products when needed).^{8,30,37,44,49}

The impact of menstrual product insecurity on product usage was also assessed. Among these 31 items,^{5,8,18,19,28,30,34,36,37,44,47,49,52,54} 13 items explored product extended or overuse,^{5,8,18,19,28,34,37,44,49,54} 12 explored product substitution (i.e., using toilet paper),^{5,8,18,30,34,36,37,44,47,49,52} two examined reusing menstrual products,^18,52 and 4 examined the ability to change products as needed.^18,28,52 Additional implications of menstrual product insecurity were also explored, such as health and psychological impacts. Of which, two items explored health impacts,^30,34 and two items examined psychological impacts.^18,50

Forty-seven items asked about frequency experiencing menstrual product insecurity.^{3–5,8,18,19,29,30,36,37,41,42,44,47–49,52,54,57,58} Of these, 17 asked about lifetime experiences,^{19,30,36,37,44,49,52,54,57,58} 14 items examined menstrual product insecurity during a specific period of time,^{3,4,8,30,37,41,44,47–49} 11 examined menstrual product insecurity specifically during the COVID-19 pandemic,^{5,18,29,37,44,47} and 5 items asked respondents to estimate their frequency of experiencing menstrual product insecurity.^3,4,8,42,48

If the full questionnaire or exact items were not included with the article, it was not always possible to decipher the precise item response options. Of the known responses for items, most of the items related to menstrual product insecurity and period poverty asked multiple choice questions (n = 32/54).^{3,4,8,18,30,34,36,42,43,48,49,52,54,57,58} Twenty items asked yes/no questions,^{5,8,20,22,29,30,36,38,39,47,49,54,57,58} and two items were open-ended.^29,42 A majority of the items were self-report, asking the respondent directly about their own experiences; however, 13 items used proxy measures asking questions of school nurses (n = 6),⁴⁷ teachers (n = 1),³⁸ physicians and hospital staff (n = 3),⁴⁹ students (n = 1),⁴² and community organizations (n = 2),⁴² about awareness of individuals who struggle to with menstrual product insecurity.

Absenteeism/consequences of menstruation

Items reflecting the absenteeism construct were described by setting, consequences beyond absenteeism, reason for absenteeism (i.e., menstruation, symptoms, supplies), reason for other consequences of menstruation beyond absenteeism, and frequency of absenteeism. We also assessed the items’ question and response type.

Among the 65 items reflecting absenteeism and consequences of menstruation, 27 items assessed school absenteeism,^{3,18–20,23,26,30,36,42,47–49,54,57,58} and 7 examined work absenteeism.^{19,37,42,44,57,58} Some items asked about the consequences of menstruation beyond absenteeism at school and work, including effects on cultural practices and other social activities. Specifically, 17 items examined other school impacts of menstruation such as the impact on learning/academic performance, being disciplined at school, and late arrival or early dismissal,^{18,20,30,38,47–49,54,58} 3 items assessed work impact (i.e., impact on performance, interference with job),^33,55,58 18 assessed other social impacts (i.e., declining social meetings, missing activities outside of school, not going out with friends),^{18,19,21,26,28,34–36,40,42,54,58} and 2 items examined cultural restrictions during menstruation (i.e., religious restrictions, food restrictions).^23,26

Beyond just the consequence of menstruation, 43 items assessed reasons for menstruation-related absenteeism^{3,18,20,23,26,30,33,34,36,42,47–49,54,57,58} and 31 assessed reasons for consequences beyond absenteeism.^{18,20,26,28,30,35,36,42,47–49,54,55,58} The reasons were described based on menstruation, supplies, symptoms, and culture. Items describing menstruation-related causes were described as any item that explicitly mentioned menstruation or referred to menstrual bleeding as the reason for absenteeism or additional consequences. Symptom-related causes reflected absenteeism and consequences due to menstrual symptoms such as pain and cramping. Absenteeism due to supplies-related reasons was described as difficulty obtaining products, and cultural-related reasons were reflected by restrictions in participating in activities due to cultural beliefs and practices. For reasons for absenteeism, 20 items examined menstruation-related causes,^{3,20,23,26,33,36,47–49,54,57,58} 14 examined supplies-related reasons,^{3,18,20,30,34,36,42,48,49,57,58} 8 examined symptom-related reasons,^{3,20,23,36,48,49,57,58} and 1 examined cultural reasons for absenteeism.²³ There were 31 total items examining reasons for consequences beyond absenteeism due to menstruation. Of which, 17 items assessed menstruation-related reasons,^{20,26,30,35,36,47–49,54,55,58} 11 assessed supplies-related reasons,^{18,30,36,42,49} and 3 assessed symptom-related reasons.^28,36,49

Twenty-three items asked about the frequency of absenteeism and other consequences due to menstruation.^{3,23,30,36,42,48,49,54,55,57,58} Of which, 11 asked about lifetime experiences,^{30,36,49,54,55,57,58} 9 items examined absenteeism/consequences during a specific period of time,^3,23,42,48 and 3 items examined estimated days missed due to menstruation.³⁰

Of the known response options for items related to absenteeism and the consequences of menstruation, most of the items asked multiple choice questions (n = 36/51).^{3,18,20,23,28,30,36,42,48,49,54,57,58} About 14 items asked yes/no questions,^{3,30,33,35,36,38,48,55} and 1 item was open-ended.³⁸ Again, a majority of the items were self-report; however, five items relied on proxy measures.^38,42,47,58

Product source

Items within the product source construct reflected product source, product location by source, frequency of using products from various sources, and funding/purchaser. Similar to the previous two constructs, we also assessed question type and response type for items within the product source construct.

Among the 18 items reflecting product source, several of which covered multiple sources, 19 items assessed various product sources including school (n = 12),^{3,30,38,39,47,58} university (n = 1),⁴⁹ healthcare provider (n = 1),⁵⁸ family member (n = 1),⁵⁸ friend (n = 2),^{30, 58} and community organization (n = 2).⁴²

Items asked about the various location(s) of products within sources including school, university, and healthcare. Among items examining locations within schools, three inquired about products in bathrooms,^30,39,47 three in health clinics,^3,30,47 four in nurse’s office,^3,30,47,58 six from teacher/staff,^{3,30,38,39,47,58} two from administrative office,^30,47 and one in the gym locker room.³⁰ One item explored locations within the university, including bookstore, student bathrooms, wellness center, dorm, and campus convenience store.⁴⁹ Furthermore, one item assessed product availability from doctors/medical staff.⁵⁸

Five items explored the frequency of receiving menstrual products from sources during a specified time period (i.e., in the last year, ever in the past).^3,42

Twelve items explored the source of funding for menstrual hygiene products including self (n = 3),^18,30,58 school (n = 2),^38,47 teacher/staff (n = 2),^38,47 family member (n = 1),¹⁸ friend (n = 1),¹⁸ donation (n = 2),^42,47 and community organizations (n = 1).⁴⁷

Of the known responses for product source items, most of the items asked multiple choice questions (n = 10/16),^{3,18,30,38,42,49,58} and six items asked yes/no questions.^{3,30,39,42,47} A majority of the items were self-report, asking the respondent directly about their own experiences; however, five items used proxy measures asking of teachers/staff (n = 1),³⁸ school nurses (n = 2),⁴⁷ and community organizations (n = 2) about who provides menstrual products for individuals to use and where.⁴²

Discussion

Menstrual health and hygiene research is a rapidly expanding field. Especially over the past decade, its growth has been particularly dramatic in HICs. However, our review demonstrates that research on menstrual health and hygiene is hindered by substantial heterogeneity in measurement items, domains, and operational definitions across studies. This lack of comparability is more than a methodological inconvenience; it fundamentally limits the field’s ability to synthesize evidence, draw valid inferences across contexts, and develop generalizable guidance for policy and practice. When key constructs such as menstrual hygiene behaviors, knowledge, or access are defined and measured differently across settings, findings cannot be reliably aggregated, hiding the true patterns in population needs and impeding progress toward evidence-based interventions. By systematically documenting this variability and identifying areas where measures differ the most, our study highlights the urgent need for a validated measurement approach to strengthen the scientific foundation of menstrual health research.

Our review indicated that there is no standard, validated measurement for MHM, menstrual product insecurity, or period poverty and its consequences for the general population in HICs. Measurement scales reporting psychometric properties beyond just face and content validity focus on specific sub-populations, such as women serving in the military,^33,46,50,56 those with cerebral palsy,⁵¹ and injection drug users.²⁷ While these sub-populations are certainly important groups for measurement, the scales are focused on particular aspects of menstruation, such as menstrual suppression. Similarly, while there has been development and validation of menstrual hygiene measurement scales in Uganda¹⁵ that are also being used in other LMICs,^59–61 these validated measures may not be appropriate and applicable for the context of HICs. Importantly, even among specific sub-populations, there is not yet any standardized measurement for menstrual product insecurity or period poverty, two of the most widely discussed and policy-relevant domains in recent MHM discourse.^13,14

This review found that menstrual product insecurity was one of the most frequently measured constructs, with 100 items capturing a wide range of experiences from affordability and accessibility to coping mechanisms like product overuse and substitution. This multidimensionality reflects the complex and intersectional nature of menstrual product insecurity in HICs, where stigma, cost, and inadequate institutional support converge. However, only three items across all studies explicitly used the term “period poverty,” highlighting a disconnect between current policy discourse and the language used in measurement. While this construct has gained policy attention,^62,63 tools to rigorously quantify it in diverse HIC settings remain underdeveloped.

Similarly, absenteeism due to menstruation, whether from school, work, or social activities, was another commonly assessed domain, but questions were inconsistent in focus and often lacked specificity in recall periods or underlying reasons for absence, such as lack of supplies, symptoms, or cultural restrictions. Despite the potential educational and economic consequences of menstrual-related absenteeism,¹⁰ few tools have explored its long-term impact.

Items related to the source of menstrual products were less frequently included, and when they were, they often focused on educational institutions. Few tools assessed the role of community organizations, local government resources such as libraries, health systems, or workplace settings in providing products. While a growing number of policies mandate free product provision in public spaces,^13,14 measurement tools have not kept pace with these policy changes. There is a clear need for instruments that assess both the availability and acceptability of product provision across diverse public and private settings.

Given the increased recognition of menstrual hygiene needs in the United States and other HICs, the consequences of period poverty, and the rapidly expanding nature of research, interventions, and policies seeking to address these challenges, there is a critical need to develop and standardize measurement tools appropriate for and applicable to HIC contexts. The menstrual hygiene measurement and validation work in LMICs and specific sub-populations within the United States provides a foundation; however, measures developed specifically for and validated in the general population in HICs should be a priority for the field.

Epidemiology seeks to understand the distribution of health conditions and the risk factors associated with those conditions in order to monitor changes over time and evaluate the effectiveness of interventions and policies designed to improve those conditions.⁶⁴ Key to being able to understand these patterns is ensuring that the measure actually measures what it claims to measure (validity) and making sure the measure is stable and consistent when used repeatedly under similar conditions (reliability).⁶⁴ Establishing such validity and reliability requires multiple studies over time.

Because the experience of menstruation varies individually and is heavily culturally embedded, multiple measurement tools might be needed for different contexts and aspects of menstruation. Within the field of menstrual health and hygiene, menstrual product insecurity and period poverty should be priority constructs for measurement development and validation. Not only are the current measures being used not validated, but also our review shows that they vary widely in what they capture, making it difficult to compare data across studies or overtime. The development and validation of measurement of food insecurity in the U.S. building off previously validated measures used in LMICs⁶⁵ can serve as a roadmap for developing similar measures for menstrual product insecurity and period poverty in HICs.

Limitations

This study provides a comprehensive review of the current state of expansive measures used to assess menstrual health and hygiene and product insecurity in HICs to date. Such a review can serve as a foundation for developing more standardized and validated measurement tools. There are some limitations to this review, however, to acknowledge. First, we only reviewed articles published in English. A substantial amount of research in the field is emerging from non-English speaking, HICs that may provide additional insights and help inform the development of standardized English-language measures. Next, menstruation is heavily embedded in cultural contexts. Therefore, even measures developed and validated in HICs might not be applicable to all settings and populations between and within those countries. Measures may need to be tailored and adapted to specific settings and populations. In addition, most of the studies included were conducted in the United States, limiting the generalizability of this review’s findings to a broader HICs. Furthermore, the lack of consistent access to full survey instruments limited our ability to evaluate the exact item wording or response scales in some cases. Finally, we did not conduct an appraisal of the quality of the studies included. We merely reviewed and assessed measures as reported in the studies. Despite these limitations, we believe having such a review of the current state of measurement will help advance the field and refine future measurement.

Conclusion

Standardized, validated measurement is an essential epidemiological tool. It is crucial for surveillance and allows for comparison between population groups, for assessment of change over time, and for evaluation of the effectiveness of interventions and policies. As more interventions and policies are enacted to help alleviate period poverty and improve menstrual health and hygiene, we need validated measures to help document effects and assess change. Given how nascent the field is, it is understandable that validated measures are not yet standard practice; however, now we need to dedicate the time and resources to developing, validating, and disseminating such measures.

Drawing on lessons from the development of standardized food insecurity measures in the United States,⁶⁴ we outline a brief roadmap to guide the creation of validated menstrual health measurement tools. First, the field should establish consensus on core constructs through a stakeholder-driven process. Second, candidate items should be developed and refined using qualitative methods to ensure clarity and cultural relevance. Third, these items should undergo rigorous psychometric testing in diverse populations to establish reliability, validity, and comparability. Finally, refined instruments should be piloted in large surveys or surveillance systems to assess feasibility and support broader adoption. Following this structured approach can move the field toward harmonized, actionable menstrual health metrics.

Supplemental Material

sj-docx-1-whe-10.1177_17455057261430205 – Supplemental material for Measuring menstrual hygiene in high-income countries: A scoping review

Supplemental material, sj-docx-1-whe-10.1177_17455057261430205 for Measuring menstrual hygiene in high-income countries: A scoping review by Mintesnot Tenkir Teni, Jamirah Abdul-Haqq, Edvanio Fernandes and Anne Sebert Kuhlmann in Women's Health

Footnotes

Acknowledgements

We would like to thank Angela Spencer, research librarian at Saint Louis University, for her assistance with the initial search.

ORCID iDs

Mintesnot Tenkir Teni

Anne Sebert Kuhlmann

Ethical considerations

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Author contributions

Mintesnot Tenkir Teni: Conceptualization; Methodology; Writing – review & editing; Writing – original draft; Software; Formal analysis; Data curation.

Jamirah Abdul-Haqq: Writing – original draft; Writing – review & editing; Methodology; Data curation; Software; Formal analysis; Visualization.

Edvanio Fernandes: Writing – review & editing; Methodology; Data curation; Software; Formal analysis.

Anne Sebert Kuhlmann: Conceptualization; Methodology; Data curation; Visualization; Writing – original draft; Writing – review & editing; Supervision; Formal analysis.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Not applicable.

Supplemental material

Supplemental material for this article is available online.

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