Open access Protocol Menstrual health and period poverty among young people who menstruate in the Barcelona metropolitan area (Spain): protocol of a mixed-­methods study Laura Medina-­Perucha ‍ ‍,1 Constanza Jacques-­Aviñó,1,2 Carme Valls-­Llobet,3 Rosa Turbau-­Valls,4 Diana Pinzón,5,6 Lola Hernández,7 Paula Briales Canseco,8 Tomàs López-­Jiménez,1,2 Enara Solana Lizarza,9 Jordina Munrós Feliu,10 Anna Berenguera ‍ ‍1,6 To cite: Medina-­Perucha L, ABSTRACT Jacques-­Aviñó C, Valls-­Llobet C, Strengths and limitations of this study Introduction The importance of menstrual health has et al. Menstrual health and been historically neglected, mostly due to taboos and ►► This study will address an important research gap on period poverty among young people who menstruate in the misconceptions around menstruation and androcentrism menstrual health and period poverty in high-­income Barcelona metropolitan area within health knowledge and health systems around the settings, from a gender and intercultural approach. (Spain): protocol of a mixed-­ world. There has also been a lack of attention on ‘period ►► A mixed-­methods design will allow for the integra- methods study. BMJ Open poverty’, which refers to the financial, social, cultural tion of quantitative (descriptive) and qualitative (in-­ 2020;10:e035914. doi:10.1136/ and political barriers to access menstrual products and depth) data. bmjopen-2019-035914 education. The main aim of this research is to explore ►► This study includes collaborations with a variety ►► Prepublication history and menstrual health and experiences of period poverty among of key actors, following Responsible and Research additional material for this young people who menstruate (YPM). Innovation (RRI) guidelines. paper are available online. To Methods and analysis This is a convergent mixed-­ ►► The dissemination strategy includes a variety view these files, please visit of audiences and will be cocreated with study methods study, which will combine a quantitative the journal online (http://​dx.​doi.​ participants. org/​10.​1136/​bmjopen-​2019-​ transversal study to identify the prevalence of period poverty among YPM (11–16 years old), and a qualitative ►► The combination of data collection methods, and us- 035914). ing an RRI and participatory research approach will study that will focus on exploring menstruation-­related Received 21 November 2019 require increased resources and time. experiences of YPM and other groups (young people Revised 17 June 2020 who do not menstruate (YNM); primary healthcare Accepted 30 June 2020 professionals; educators and policy-­makers). The study will be conducted in the Barcelona metropolitan area INTRODUCTION between 2020 and 2021. Eighteen schools and 871 YPM Research on menstrual health is still scarce. will be recruited for the quantitative study. Sixty-­five YPM Moreover, most research has been conducted will participate in the qualitative study. Forty-­five YNM and in low-­income countries,1–3 neglecting its 12 professionals will also be recruited to take part in the need in high-­ income regions. Menstrual qualitative study. Socioeconomic and cultural diversity will health is associated with the access of people be main vectors for recruitment, to ensure the findings who menstruate to accurate information are representative to the social and cultural context. on menstruation, menstrual products and Descriptive statistics will be performed for each variable to clean and safe washing facilities. Menstrual identify asymmetric distributions and differences among health also needs to be understood as a tool groups will be evaluated. Thematic analysis will be used for health promotion, and it is linked to for qualitative data analyses experiences related to the menstrual cycle. © Author(s) (or their Ethics and dissemination Several ethical issues have Good menstrual health also includes tack- employer(s)) 2020. Re-­use been considered, especially as this study includes the ling menstruation-­related taboos, stigma and permitted under CC BY-­NC. No participation of underage participants. The study has commercial re-­use. See rights discrimination.4 Promoting menstrual health received ethical approval by the IDIAPJGol Research is key to reach gender equity and promote and permissions. Published by BMJ. Ethics Committee (19/178 P). Research findings will health among people who menstruate. be disseminated to key audiences, such as YPM, YNM, For numbered affiliations see Menstrual health has even been suggested parents/legal tutors, health professionals, educators, end of article. as a vital sign.5 6 Despite the growing inter- youth (and other relevant) organisations, general Correspondence to national commitment to focus on promoting community members, stakeholders and policy-­makers, Dr Laura Medina-­Perucha; menstrual health, there is still much to be and academia. ​lmedina@​idiapjgol.​info done.2 In this study, we will focus on ‘people Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 1 Open access who menstruate’ rather than ‘women’ not to exclude (eg, normalisation of menstrual pain) and structural people who have a menstrual cycle but are not women/ (eg, not being able to get sick leave for menstrual pain) do not identify as women (eg, male transsexual or male sanctions. transgender). The menstrual cycle is not a health condition to be medi- Activist-­ led movements have increased awareness on calised. However, this is not how it seems to be conceived the negative impact on the cost of menstrual products, within society and healthcare systems. This project stems sociocultural practices and views on menstruation have from an opposition to the predominant androcentrism on women’s health and well-­being. These movements aim in health science and healthcare systems. The concept of at promoting a ‘menstrual culture’ that demystifies the androcentrism refers to having men (male humans) as menstrual cycle and are based on feminist and sociocul- the reference, the norm and the example for all humans. tural paradigms. Together with some health professionals, In the health context this has translated into the invisibil- activism in Spain is already suggesting body awareness isation of women, the female body and women’s health and knowledge about one’s menstrual cycle as tools for in health science, policy and practice.8 10–12 As briefly health promotion. Menstrual health education is crucial mentioned already, this project also questions the role of to understand and improve how people who menstruate the industry (menstrual products and pharmaceutical) in relate to their menstrual cycle.4 7 However, the role of the medicalisation and sociocultural conceptualisations the ‘menstrual products’ and pharmaceutical industries of the menstrual cycle and menstruation.8 Instead, it is in women’s menstrual health is strong. These are the important that the menstrual cycle is understood as a companies which are delivering menstrual health educa- natural process that is associated with good health. This tion in schools in Spain. Considering that these events are means that educating society and professionals is a priority enough for ‘menstrual health education’ is questionable, to promote health among young people who menstruate as these companies rather focus on selling their products (YPM). Increased education and a more positive concep- and on medicalising menstruation instead of delivering tualisation of the menstrual cycle and menstruation could high-­quality education on the menstrual cycle and the help YPM being more aware of their bodies. In turn, this wide range of products available.8 In the meantime, many could help encourage menstruators to care for their people who menstruate in Spain seem to still be unaware menstrual and general health, and aid the identifica- of how their menstrual cycle works and its relationship tion of some health conditions such as endometriosis.13 with their overall health.8 Improved education could also lead the disassociation of Focusing on young people is crucial to understand menstruation and pain, and challenge myths and beliefs their conceptions and experiences of menarche (first around the menstrual cycle and the use of hormonal menstruation). Good health education among young contraception. Last but not least, education could reduce people is a priority as their bodies are changing while menstruation-­related stigma and discrimination. reaching adulthood. As previously reported in a study by One aspect of menstrual health is the access to Plan International UK,4 it is essential that young people menstrual products. Research in other countries, such get access to menstrual health education, health services as Uganda3 and the UK4 has highlighted experiences of and products that protect their health and well-­being. period poverty among young women. This term refers In this study, menstrual-­related myths and taboos were to barriers (financial, social, cultural and political) in prevalent among young people. Stigma and embarrass- accessing menstrual products, menstrual education ment were a reality for many girls as, for example, most and access to healthcare services. Plan International of them did not feel comfortable discussing menstruation UK4 recently explored period poverty in a high-­income with their school teachers. Besides and very importantly, country through focus groups with 64 adolescents. Their most girls explained how they were unaware of what was report revealed that 1 in 10 adolescents experience period happening in their bodies and what to do when they first poverty in the UK. However, and to our knowledge, there got their menstruation.4 Another reason to focus on chil- have been no attempts to identify the prevalence of dren and adolescents is that they are vulnerable groups to period poverty at a community or population level. experience stigma, discrimination, and social and health Despite social movements to promote menstrual health inequities. and to reduce menstrual products’ taxes in the last few Inequities between people who menstruate and people years, menstrual health in Spain continues to be ignored. who do not menstruate are also to be highlighted. These This is reflected in national and regional public health are, for example, visible through the (still prevailing) strategies, in which menstrual health is never present. stigma and discrimination towards people who menstruate Even when 27.7% of children were at risk of poverty in and menstruation itself.4 In line with this argument, Catalunya in 2017,14 experiences of period poverty among productivity loss due to presentism and absenteeism children and adolescents have not been explored. Social, at schools and workplaces among people who experi- cultural, financial and political barriers to promote ence menstrual pain needs to be considered too.9 Social menstrual health, stigma and discrimination and the and health inequities among people who menstruate elimination of period poverty have also been overlooked. (compared with people who do not menstruate) can be Besides, menstrual products are not considered necessity also explained when menstruating is a source of social goods by law in Spain, holding a 10% tax (Spanish Law 2 Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 Open access 37/1992, 28 December 2018). Although in October 2018 guides) and writing research publications and other the Spanish government guaranteed that tax retentions dissemination materials. Taking this RRI approach will be on menstrual products should be reduced to 4%, this tax key to conduct inclusive research not only for but with the reduction has not been applied yet. community and other key agents. This research is based This study will explore menstrual health and experi- on a gender-­based8 16 17 and intercultural approach.18–20 ences of period poverty among YPM. We also hope to iden- These approaches go in line with acknowledging socio- tify barriers and facilitators that could promote menstrual cultural differences and embracing a respectful and non-­ health through the access of good-­quality education and discriminatory perspective on research. healthcare. Also, to explore ways to improve menstrual health experiences in YPM and reduce period poverty. Study design This study will provide recommendations for future This research is a convergent mixed-­methods study that research, policy and practice, aiming at addressing will include a quantitative study and a qualitative study. social inequities of health in YPM (and especially among Quantitative research will allow to quantify the extent of those that may be experiencing period poverty) in Spain period poverty and some menstrual health experiences. and other high-­income countries with similar sociocul- Qualitative research will provide an in-­ depth explora- tural contexts. The views of young people who do not tion of these phenomena. It will start in September 2019 menstruate (YNM) and professionals will also be consid- and end in September 2021. A Gantt chart is provided in ered in this project. Through this research, our team aims figure 1. Data will be collected in Catalan and Spanish, to start a line of research on menstrual health and period the two official languages in the Barcelona metropolitan poverty in the area of Barcelona, hoping to scale up the area. study to other areas in Spain. ​Quantitative study This is a cross-­sectional questionnaire-­based study. A non-­ standardised questionnaire (see online supplementary AIMS AND OBJECTIVES material) will be used to calculate the composite main This project aims to explore menstrual health and expe- variable ‘period poverty’. Other variables that will be riences of period poverty among YPM (11–16 years old). measured and will be used to develop the variable ‘period The study will be conducted in the Barcelona metropol- poverty’. These will be: (1) use of menstrual products, (2) itan area between 2019 and 2021. financial (and other) barriers to access menstrual prod- The objectives will be: ucts, (3) use of hormonal contraception, (4) period pain 1. To identify the prevalence of period poverty in YPM. and menstrual disorders, (5) mental health, (6) access to 2. To explore sociocultural understandings of menstru- menstrual health consultations, (7) menstruation-­related ation and menstrual health in YPM, YNM of the same school absenteeism, (8) menstruation-­ related interfer- age, health professionals, teachers, activists and policy-­ ence on school performance and other activities, (9) makers. menstruation-­ related stigma and discrimination, (10) 3. To explore experiences of menstruation and period access to menstrual health education and (11) menstrual poverty among YPM. hygiene and management. 4. To explore menstruation-­related stigma and discrimi- Sociodemographic data will also be collected (age, nation. school, primary healthcare centre, deprivation index, 5. To identify barriers and facilitators to promote men- household composition). All variables and sociodemo- strual health, and to access education and healthcare graphic data (except for the deprivation index) will be for menstrual health. collected using the self-­ reported questionnaire. The 6. To identify opportunities to improve menstrual health-­ deprivation index will be calculated based on available related experiences of YPM and reduce period poverty. databases such as the MEDEA (Mortalidad en áreas 7. Provide recommendations for future research, policy pequeñas Españolas y Desigualdades Socioeconómicas y and practice. Ambientales) deprivation index.21 METHODS AND ANALYSIS ​Qualitative study The study will be coordinated by the research team at There will be three phases of data collection for the qual- the (Research Centre name). However, a working group itative study: of women that includes health professionals, educators, Phase I. Semistructured interviews using photo elicita- youth representatives and menstrual health activists has tion techniques22: 20 YPM will take part in semistructured been composed, considering responsible research and interviews using photo elicitation techniques. These inter- innovation (RRI) guidelines.15 The members of the views will take place in schools making sure that partici- working group will regularly contribute to the develop- pants are in a familiar and comfortable environment. The ment of the project attending regular meetings. They interviews will focus on objectives 2–4. will also be involved in developing key study materials Phase II. Group discussions: Nine group discussions (eg, study protocol, non-­validated questionnaire, topic (three with YPM only, three with YNM and three mixed) Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 3 Open access Year 1 Year 2 STUDY PHASES TASKS TEAM Months Months 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 Meetings research group Research team Transversal Meetings working group Working group Ethical approvals Research team Creation of working group Research team Study preparation Development of study protocol Working group Development of study materials Working group Establish contacts for recruitment Working group Recruitment schools Working group Recruitment participants Research team Recruitment and data Completion of questionnaires Research team collection Individual interviews Research team Group discussions Research team World Café Research team Transcribing Research team; transcriber Quantitative analyses Research team Data analyses Qualitative analyses Research team Discussion of results Working group Dissemination project Participants; working group Dissemination of final product Participants; working group Dissemination of results Working group Publication 1 (study protocol) Working group Dissemination Publication 2 (quantitative data) Working group Publication 3 (qualitative data; interviews and group discussions) Working group Publication 4 (qualitative data; world café) Working group Evaluation and impact Impact evaluation Working group Figure 1 Gantt chart. will be run with an estimate of 45 YPM and 45 YNM. Partic- The main topic areas will be (1) sociocultural under- ipants for the group discussions will be stratified by age standings of menstruation and menstrual health; (2) (11–12 years old, 13–14 years old and 15–16 years old). personal experiences of menstruation; (3) experiences of Group discussions will be conducted within the natural period poverty; (4) experiences of menstruation-­related context of a classroom. Observation and group discussion stigma and discrimination; (5) barriers and facilitators to techniques will be used to collect data. Objectives 2–6 will promote menstrual health, and to access education and be covered in this phase of data collection. healthcare for menstrual health; and (6) opportunities Phase III. World Café23 Health professionals, teachers, to improve menstrual health-­related experiences of YPM policy-­ makers, activists and youth representatives will and reduce period poverty. be invited to participate in a world café. There will be a All materials for the quantitative and qualitative studies maximum of 12 professionals in the session. The aim of will be piloted with the target population before using phase III will be to mainly address objectives 4–6. them for data collection. Materials Participants ​Quantitative study There will be different groups of participants: YPM, YNM A non-­ standarised questionnaire has been devised for and professionals (health professionals, teachers, policy-­ this study by the working group (see online supplemen- makers, activists and youth representatives). tary file S1). Several meetings were organised to work on the development of the variables and the question- ​Participant selection naire, following the guidance of previous research and For both the quantitative and qualitative studies recruit- published work on questionnaire design.24 ment will be non-­probabilistic (as not all schools and indi- viduals will have the same probability of being recruited) ​Qualitative study and purposive (as schools and participants will be selected Topic guides will be developed for each phase of the qual- based on the requirements of the study). itative study. Developing the topic guides will be a collabo- YPM and YNM will be recruited from (public, private rative process between the research team and the working and semiprivate) schools in the Barcelona metropolitan group. The topic guides will be based on the aims of this area. Schools will be identified to be representative of the research, previous evidence, the team’s expertise and socioeconomic diversity in the Barcelona metropolitan data previously collected for this study (phase II and area. The MEDEA index21 will be used to determine the phase III). socioeconomic level of each school. Cultural diversity will 4 Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 Open access also be a factor for recruiting schools and individuals. The Table 2 Inclusion and exclusion criteria of young people team will ensure that the experiences of socially excluded who do not menstruate (YNM) communities, such as the gipsy community and migrants, YNM are represented in this research. Considering that around 18 schools will be recruited, we will aim to recruit three Inclusion criteria Exclusion criteria or four schools from each of the five MEDEA levels. First, Are between 11 and 16 years Are below 11 or above 16 permission will be requested from the council of each old years old municipality where recruitment will take place. Then, Are attending a participating Have (or will) menstruate schools will be contacted and informed about the study, school based on a list of schools in the Barcelona metropolitan Have not (and will not) Cannot understand and/or area and professional contacts of the working group. The menstruate provide consent research team will organise meetings at participating Have given their consent to Cannot communicate well in schools to inform staff and adolescents about the study. participate Catalan or Spanish Information sheets and consent forms will be given to Parents or legal tutors have   adolescents to inform and ask parents and legal tutors for signed the consent form consent to participate. An adapted information sheet will Have a good command of   be given to minors. Parents and legal tutors will be asked Catalan or Spanish to return a signed copy of the consent form if they want their children to participate. This procedure will be used for each stage of the project involving adolescents (quan- The sample size is based on power calculations consid- titative study and phase I and II of the qualitative study). ering the composite variable ‘period poverty’ as the main In phase III of the qualitative study, professionals will variable. Maximum indetermination of the main variable be recruited using snowballing techniques and by identi- (proportion of 50%) was assumed. It was also consid- fying key informants for this study. Diversity in the profes- ered that there are 53 354 young girls attending schools sionals’ background and expertise will be considered to in the Barcelona metropolitan area between 11 and 16 ensure diversity in the discourses. Participants will be years old. These assumptions were considered in order to required to sign an informed consent to take part in the obtain a precision of 5%, expecting that 50 young girls of study. each participating school will take part in the study. Also, I​nclusion and exclusion criteria due to the effect of the design an interclass correlation of The inclusion and exclusion criteria are available in 0.0263 will require a minimum of 871 participants (and 18 tables 1–3. The researchers will not actively exclude schools). These estimates have been calculated assuming people with functional diversities, unless they do not an alfa risk of 5%. PASS software was used for the sample meet the inclusion criteria (eg, they cannot give consent size calculations (PASS V.15). or communicate with the researchers). ​Qualitative study Sample size Sixty-­ five YPM, 45 YNM and 12 professionals (health ​Quantitative study professionals, teachers, policy-­makers, activists and youth A total of 871 YPM will be recruited for the quantitative representatives) will be recruited for the qualitative study. study in 18 schools in the Barcelona Metropolitan area. The sample size will be dependent on data saturation. Data analysis plan Table 1 Inclusion and exclusion criteria of young people ​Quantitative study who menstruate (YPM) Descriptive statistics will be used for each variable to iden- YPM tify asymmetric distributions. The continuous variables will be analysed as mean (SD) or median (25th and 75th Inclusion criteria Exclusion criteria Are between 11 and 16 years Are below 11 or above 16 old years old Table 3 Inclusion and exclusion criteria of professionals Are attending a participating Have not (and will not) Professionals school menstruate Have (or will) menstruate Cannot understand and/or Inclusion criteria Exclusion criteria provide consent Have experience working Do not have experience Have given their consent to Cannot communicate well in in relevant areas of/for working in relevant areas of/for participate Catalan or Spanish menstrual health menstrual health Parents or legal tutors have   Have signed the consent Cannot understand and/or signed the consent form form provide consent Have a good command of   Have a good command of Cannot communicate well in Catalan or Spanish Catalan or Spanish Catalan or Spanish Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 5 Open access centiles) based on the normality/non-­normality of the the Spanish Law on Biomedical Research (14/2007); and distribution, and categorical variables will be described as the LOPD (Spanish Law on Personal Data Protection) percentages. To evaluate differences among groups, the (3/2018). appropriate statistics will be applied based on the type of variable and their distribution (χ2, F-­distribution, Student’s ​Informed consent t-­distribution, analysis of variance, Mann-­Whitney U and Verbal and written informed consent will be requested Kruskal-­Wallis). To estimate the magnitude of the associ- from all participants prior to their participation in ations between the selected variables and period poverty, the study. Most participants will be minors. This has prevalence ratios and their 95% CIs will be computed by important ethical implications. All information will be general linear models (Poisson regression models with given to underage participants in a comprehensive way, robust variance and logistics models). and study materials will be adapted to ensure readability and comprehensiveness. Parents or legal guardians will ​Qualitative study be notified of their adolescents’ invitation to the study. Qualitative data will be analysed using thematic content A signed written consent will be requested from all analysis.23 Once the audio recordings are transcribed, the parents or legal guardians for all underage participants. researchers will familiarise themselves with the data. This The researchers will ensure that participants are able to will lead to preanalytical insights of the data. The next consent, and that they understand what their participa- step will be to (1) identify relevant themes within the text, tion entails. (2) divide the text into units of meaning, (3) coding of the data, (4) generation of categories by grouping codes, ​ onfidentiality and anonymity C (5) analysis of each category and (6) elaboration of new Confidentiality and anonymity will be carefully ensured. text. Results will then be discussed with the working group Contact details will only be requested to those partici- until consensus is reached (triangulation). pants that are willing to take part in succeeding stages of the study. Physical identifiable data will be securely stored Patient and public involvement at the IDIAPJGoL in a locked cabinet. Digital information The research questions and aims of this study were driven will be securely stored at the IDIAPJGoL secure portal. by community-­led social movements on menstrual health Only the research team will have access to the data. All and period poverty. Key agents and community members data presented when disseminating the findings from were consulted to design the study, being some of these this study will be anonymised. All identifiable data will agents part of the working group. The working group will be removed from transcriptions and participants will be be actively involved in all stages of the study. Together with assigned a participant code. Anonymity in the photo- participants, the working group will also contribute to the graphs used in the photo-­elicitation interviews will also be communication and dissemination of the findings (see ensured. The team will do this by not using photographs Dissemination Strategy section on page 12). All materials in which people are identifiable, unless written consent used for this study (eg, questionnaire and topic guides) is given from identifiable people in the photographs. will be designed and piloted with the target population. Anonymised data will be made available on request to the authors. Ethics and dissemination ​Ethical considerations ​Potential risks We have obtained the necessary ethical approvals Taking part in this study will involve the discussion of prior to the start of the research from our organisa- sensitive topics (ie, menstrual health, situations of ineq- tion (IDIAPJGoL) (19/178 P). We have considered a uity, sexual relationships and other related topics) and number of ethical issues. A main consideration is that this involves the inclusion of a vulnerable group (minors). research involves the participation of individuals who are Discussing sensitive topics and the inclusion of minors not able to give consent (minors). Adolescents’ consent are necessary for the purposes of this study. In order to will be granted through representation (ie, parents or minimise these issues, information about the nature of legal tutors) according to the Spanish Law on Biomedical the study will be disclosed prior to seeking consent and Research (14/2007). before data collection. The researchers will conduct the All activities included in the study will be carried out study sensitively at all times. according to existing guidance in ethics as indicated A protocol has been prepared in case the researchers in the Universal Declaration on Bioethics and Human had immediate concerns of harm, or a participant gets Rights adopted by UNESCO (19/10/2005); the Council distressed during their participation in the study. If this of Europe Convention for the Protection of Human happened with underage participants, their school tutor Rights and Dignity of the Human Being with regard to and parents will be informed (with the participants’ the Application of Biology and Medicine (1997) and its permission). Participation will be paused or stopped if additional protocol on biomedical research (2005); the a participant gets distressed. It will be the participant’s Helsinki Declaration (2013) and relevant EU laws (Euro- decision whether they decide to continue taking part pean Parliament and Council Directive 2001/20/EC); in the study. The research team will ensure that all 6 Medina-­Perucha L, et al. BMJ Open 2020;10:e035914. doi:10.1136/bmjopen-2019-035914 Open access participants are able to seek support and/or advice if Acknowledgements We would like to thank all women (and men) from the needed. community who contributed to the ideas captured in this protocol. We would like to specially thank Carmen Revuelta Lisa, Ramona Ortiz López and Mònica Isido All participants will be made aware of their right to Albaladejo for their contributions to elaborating the materials and setting up withhold information that they are not willing to share, as recruitment and data collection. Also, we want to acknowledge Patryk Bialoskorski well as withdrawing from the study or removing their data for his contributions revising the language in this article. at any time (prior to data analyses). Contributors LM-­P has led and coordinated the conception and design of this Participants taking part in the interviews, group discus- study. She has written this manuscript. AB has been involved in the conception and design in this study. She has reviewed and made substantial contributions to this sions and World Café will receive a €10 voucher as a token manuscript. TL-­J has contributed to the design of the quantitative study, performed of thanks for their participation. Participants will also power calculations and written the plan for the quantitative data analyses. He has receive a debriefing form that includes a list of resources reviewed and made substantial contributions to this manuscript. CJ-­A, CV-­L, RT-­V, (books, websites and Instagram accounts) to learn about DP, LH, PBC, ESL and JMF have contributed to the design of this study. She has reviewed and made substantial contributions to this manuscript. menstrual health. Funding This work was supported by The European Society of Contraception and Reproductive Health, project number P-2019-­A-01. ​Dissemination strategy Patient and public involvement Patients and/or the public were involved in the Findings will be disseminated to key audiences. These design, or conduct, or reporting, or dissemination plans of this research. Refer to will be YPM, YNM, parents and legal tutors, health profes- the Methods section for further details. sionals, educators, youth (and other relevant) organisa- Patient consent for publication Not required. tions, general community members, stakeholders and Provenance and peer review Not commissioned; externally peer reviewed. policy-­makers, and academia. Back translation methods Open access This is an open access article distributed in accordance with the will be used to ensure the quality of any translations to Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which English. permits others to distribute, remix, adapt, build upon this work non-­commercially, The dissemination strategy will include a dissemination and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use project produced by YPM and YNM, with the support of is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. the research team. The content and format will be chosen by YPM and YNM involved in the development of this ORCID iDs dissemination project. Examples of formats would be an Laura Medina-­Perucha http://​orcid.​org/​0000-​0002-​2981-​2614 Anna Berenguera http://​orcid.​org/​0000-​0002-​0889-​2002 art exhibition or a book. The working group will also organise meetings and workshops at ‘citizen science’ events and schools, aimed REFERENCES at several key audiences. These meetings and workshops 1 Haque SE, Rahman M, Itsuko K, et al. The effect of a school-­based will involve study participants (YPM, YNM and profes- educational intervention on menstrual health: an intervention study among adolescent girls in Bangladesh. BMJ Open sionals) who will colead the sessions. 2014;4:e004607–9. The working group will prepare short reports, policy 2 Sommer M, Schmitt M, Gruer C, et al. Neglect of menarche and menstruation in the USA. 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