1166644 research-article2023 WHE0010.1177/17455057231166644Women’s HealthHolst et al. The Impact of COVID-19 on Women’s Health – Original Research Article Women’s Health Menstrual health and management during Volume 19: 1­–10 © The Author(s) 2023 Article reuse guidelines: the COVID-19 syndemic in the Barcelona sagepub.com/journals-permissions DOI: 10.1177/17455057231166644 https://doi.org/10.1177/17455057231166644 area (Spain): A qualitative study journals.sagepub.com/home/whe Anna Sofie Holst1,2, Constanza Jacques-Aviñó1,3 , Anna Berenguera1,3,4, Cristina Martínez-Bueno5,6,7, Jordina Munrós-Feliu6,8 , Diana Pinzón-Sanabria9 , Carme Valls-Llobet10, Tomàs López-Jiménez1,3, Andrea García-Egea1, María Mercedes Vicente-Hernández6 and Laura Medina-Perucha1,3 Abstract Background: Available evidence suggests that menstrual health and management have been impaired during the COVID-19 syndemic. However, research in this area is scarce, and it is failing to voice the experiences of women and people who menstruate regarding their menstrual experiences. Objectives: This study aimed to explore the experiences of menstrual health and menstrual management among women and people who menstruate in the Barcelona area (Spain) during the COVID-19 syndemic. Design: This is a qualitative study, conducted taking a critical feminist approach, is embedded in the ‘Equity and Menstrual Health in Spain’ project. Methods: It includes photo-elicitation individual interviews with 34 women and people who menstruate in the area of Barcelona (Spain). Data were collected in person and through telephone calls between December 2020 and February 2021. Analyses were performed using Thematic Analysis. Results: Main findings navigated through the menstrual changes experienced by some participants, especially women living with long COVID-19, and the barriers to access healthcare and menstrual products during COVID-19. While some participants experienced menstrual poverty, this did not appear to be exacerbated during COVID-19. Instead, access to menstrual products was compromised based on products’ availability and mobility restrictions. Menstrual management and self-care were generally easier, given that menstrual experiences were almost exclusively relegated to private spaces during lockdown periods. Conclusions: Our findings highlight the need to further research and policy efforts towards promoting menstrual health and equity, considering social determinants of health, and taking intersectional and gender-based approaches. These strategies should be further encouraged in social and health crises such as the COVID-19 syndemic. Keywords COVID-19, gender, long COVID-19, menstrual equity, menstrual health, menstrual management, menstruation, qualitative research Date received: 11 January 2023; revised: 1 March 2023; accepted: 13 March 2023 1 7 F undació Institut Universitari per a la Recerca a L’Atenció Primària de Universitat de Barcelona, Barcelona, Spain 8 Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain Atenció a la Salut Sexual i Reproductiva (ASSIR) Muntanya/La Mina, 2 Universitat Pompeu Fabra, Barcelona, Spain Institut Català de la Salut, Barcelona Spain 3 9 Universitat Autònoma de Barcelona, Bellaterra, Spain SomiArte Taller, Barcelona, Spain 4 10 Departament d’Infermeria, Universitat de Girona, Girona, Spain Centro de Análisis y Programas Sanitarios (CAPS), Barcelona, Spain 5 Servei d’Atenció a la Salut Sexual i Reproductiva (ASSIR), Direcció Corresponding author: Assistencial d’Atenció Primària, Institut Català de la Salut, Barcelona, Laura Medina-Perucha, Fundació Institut Universitari per a la Recerca a Spain 6 L’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Gran Via de Sexual and Reproductive Health Care Research Group (GRASSIR), les Corts Catalanes, 587 attic, 08007 Barcelona, Spain. Barcelona, Spain Email: lmedina@idiapjgol.org Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Women’s Health Introduction social, community, political and economic participation based on having a menstrual cycle and menstruating. The COVID-19 syndemic, a concept to describe and con- ceptualize ill-health in complex pandemics, taking into Women and PWM living in Spain experienced a strict account the intersection between socio-environmental national lockdown from 15 March 2020 to 9 May 2020, and biological factors,1,2 has particularly had a negative followed by curfews and severe restrictions on mobility psychosocial impact on women and gender non-conform- throughout 2020 and 2021. Based on previous evidence on ing people,3,4 deepening gender inequities.5 Further, the the impact of COVID-19 on menstrual health in Spain,11 syndemic has affected the access to healthcare, especially this study aimed to qualitatively explore the experiences among women, low-income populations, and other of menstrual health and menstrual management among vulnerable groups.6 This was especially evident at the women and PWM in the Barcelona area (Spain) during the beginning of the syndemic, since healthcare access was COVID-19 syndemic. compromised given the saturation in healthcare systems, public health measures and the population’s fear of in­fection.5,6 Financial and practical barriers, including Methods the digital divide given that some healthcare services got virtualized,6 are other factors for the limited access to This is an explorative qualitative study using photo-elicita- healthcare. tion interviews with women (N = 31) and PWM (N = 3) Menstrual health, a public health and human rights between 18 and 47 years old in the Barcelona area (Spain) issue, has also been reportedly affected since the onset (see Table 1). Inclusion criteria were having menstruated of the COVID-19 syndemic, alongside sexual and repro- at least once in the 12 months preceding the study, being ductive health.7–10 First, through anecdotal accounts of between 18 and 55 years old, living in the area of Barcelona, women and people who menstruate (PWM) (i.e. gender and being able to communicate in Spanish, Catalan or non-conforming menstruators), and recently through an English. Main exclusion criteria were having entered men- increasing amount of scientific evidence.11–13 Menstrual opause (1 year or more without menstruating). However, it alterations reported during the syndemic include came to light that one participant had recently entered changes in the frequency, volume, length of menstrua- early menopause during the interview. For ethical reasons, tion and the menstrual cycle and in the severity of dys- this participant’s data were still included in the analyses. menorrhea.11,10,13 These menstrual alterations have been Data included in this publication are part of the ‘Equity associated with stress levels,12,14,15 socioeconomic and Menstrual Health in Spain’ project, a larger mixed- stressors SARS-COV-2 infection,16 and long COVID- methods study that took a critical and feminist approach24 19.11 Challenges for menstrual management and access to assess and explore experiences of menstrual inequity to menstrual products in the context of the COVID-19 and menstrual health in Spain. syndemic have also been reported.17–21 These reports are suggestive of how menstrual inequities have deepened Sampling and Recruitment during COVID-19.9 To our knowledge, few studies have explored men- Sampling was purposive and selective. Recruitment strual experiences during the syndemic. While most avail- strategies included social media (Instagram, Twitter and able research have investigated menstrual alterations from WhatsApp), key persons and organizations (e.g. sexual a more biomedical perspective,16,22 other studies have and reproductive health centres, non-governmental organi- focused on the challenges for menstrual management, zations, and other local organizations), and snowball sam- often in the Global South,23 and among vulnerable popu- pling. Participants were contacted by the researchers and lations in the Global North.19 It is urgent that not only key persons and organizations, including healthcare pro- menstrual alterations in the context of COVID-19 are fessionals. All participants received oral and written infor- researched and made visible, but that menstrual inequity mation on the aims and context of the study before deciding is considered a public health issue that needs to be to participate. Four potential participants contacted the addressed through public policy and in the context of researchers to take part in the study but were unreachable social and health crisis such as the COVID-19 syndemic. to set a time for the interview later on. Given the nature The authors understand menstrual inequity as of the sampling methods, the researchers were unable to know how many other potential participants refused to the systematic and avoidable differences in the access to participate. Special attention was paid to recruiting women menstrual education and healthcare, and to products, services and PWM affected by the digital divide, people living in and facilities for menstrual management, menstrual-related socioeconomic deprived areas, participants from the Roma experiences of stigma and discrimination, the lack of research community and migrant populations. Discourse diversity on the menstrual cycle and menstruation, and the barriers to was ensured by recruiting participants with different Table 1. Participants’ sociodemographic characteristics (N = 34). ID Age Country Administrative status Employment status Completed education Gender Identified Self-reported COVID-19 Self-reported Interview Holst et al. of birth as trans long location COVID-19* P1 27 Spain Spanish nationality No employment/income Primary education Woman No Yes, diagnosed by a healthcare professional No ASSIR** P2 40 Spain Spanish nationality Works full-time Secondary education Woman No Not sure No ASSIR P3 23 Spain Spanish nationality Maternity leave Professional education Woman No Yes, diagnosed by a healthcare professional No ASSIR P4 24 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P5 25 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P6 29 Spain Spanish nationality Self-employed University studies Not sure Not sure No No Telephone P7 33 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P8 35 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P9 24 Spain Spanish nationality Works full-time University studies Woman No Not sure No Telephone P10 33 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P11 33 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P12 25 Spain Spanish nationality Work full-time; Studies part-time University studies Woman No No No Public space P13 25 Spain Spanish nationality Works full-time University studies Woman No No No Public space P14 26 Spain Spanish nationality Studies full-time University studies Woman No No No Public space P15 25 Spain Spanish nationality Works part-time University studies Woman No Not sure Not sure Telephone P16 47 Spain Spanish nationality Works full-time Professional education Woman No No No Telephone P17 34 Spain Spanish nationality Works full-time University education Woman No Yes, diagnosed by a healthcare professional Yes Telephone P18 23 Spain Spanish nationality Medical leave; Studies part-time Professional education Woman and Not sure No No Telephone non-binary P19 25 Spain Spanish nationality Studies full-time; Works part-time Secondary education Woman No Yes, diagnosed by a healthcare professional No Telephone P20 20 Spain Spanish nationality Studies full-time Secondary education Woman No No No Telephone P21 35 Spain Spanish nationality Self-employed; Studies part-time University studies Woman No No No Telephone P22 18 Spain Spanish nationality Studies full-time Secondary education Woman No Not sure No Public space P23 28 Spain Spanish nationality Works full-time University education Woman No Yes, diagnosed by a healthcare professional Yes Telephone P24 20 Spain Spanish nationality Studies full-time Secondary education Non-binary Yes No No Telephone P25 37 Morocco Permanent residence Works full-time Professional education Woman No No No Telephone P26 24 Spain Spanish nationality Works part-time Professional education Woman No No No Telephone P27 35 Colombia Spanish nationality Unemployed University studies Woman No Not sure No Telephone P28 37 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P29 23 Argentina Refugee status No income Secondary education Woman No Yes, diagnosed by a healthcare professional No ASSIR P30 22 Spain Permanent residence Works full-time Professional education Woman No No No ASSIR P31 25 Pakistan Permanent residence Works full-time Professional education Woman No Yes, diagnosed by a healthcare professional No Public space P32 29 Spain Spanish nationality Works full-time University studies Woman No Not sure No Telephone P33 28 Spain Spanish nationality Works full-time University studies Woman No No No Telephone P34 38 Brazil Spanish nationality Unemployed Professional education Woman No No No ASSIR *Long COVID-19 was self-reported by participants. At the time of data collection, long COVID-19 was defined as experiencing COVID-19 symptoms for at least 4 weeks, having had a positive COVID-19 test. **ASSIR = sexual and reproductive healthcare centre. 3 4 Women’s Health characteristics (age, socioeconomic context, country of Results origin, administrative status, and gender identity). Four themes were identified: (1) menstrual changes and the experiences of those affected by long COVID-19; (2) Data collection access to healthcare services and the systemic disregard of Thirty-four qualitative interviews took place between menstrual, sexual and reproductive health; (3) COVID-19 December 2020 and February 2021, either in sexual and lockdown as an opportunity for menstrual self-care and reproductive health centres, public open spaces (e.g. city improved menstrual management; and (4) access and parks), or by telephone. Recruitment and data collection affordability of menstrual products. were significantly limited due to COVID-19 restrictions at the time of the research, hence the combination of face-to-face and telephone interviews. Besides, given Menstrual changes and the experiences of the timeframe in which we conducted the interviews, we those affected by long COVID-19 did not collect participants’ potential menstrual altera- Around half of the participants did not notice any changes tions related to COVID-19 vaccination. A topic guide in their menstruations. For four participants, this was and two photographs for the photo-elicitation were used related to being either pregnant, post-partum, in fertility for data collection, although data from the photo-elicita- treatment or in perimenopause at time of the research. tion are not included in this publication. Both the topic Other participants reported menstrual alterations since the guide and the photographs used are available as supple- start of the syndemic. Menstrual changes included a dif- mental material in a previously published article.17 ferent abundance pattern (P13, P22) (‘More blood was Interviews lasted 40 to 85 min and were conducted by coming out for more days’–P22), increased menstrual ASH and LMP. While ASH was training as a researcher pain (P15), amenorrhea during the first lockdown at the time of the interviews, LMP is an experienced qualitative researcher, and PhD in Health Psychology, When lockdown started, hmm. . . well on a personal level, and supported and trained ASH, an MPH trainee, to con- depression, fear, uncertainty, (. . .) it has affected me. And I duct the interviews. Both researchers conducting the did not have it (menstruation) for two or three months. But interviews identify their gender as women. All inter- then I don’t know if it was in May or June that it came back views were audio-recorded and transcribed verbatim by on its own.–P28 ASH and external transcribers. Data saturation criteria were considered, reaching saturation after 17 interviews. and increased tiredness during menstruation since the All participants received a 10€ voucher as a token of onset of the syndemic (P31). Other women experienced thanks for their participation in the study. more emotional alterations and an increased severity of Quality and rigour for the qualitative study have been premenstrual syndrome since the syndemic started: ‘I did ensured by following the Guba and Lincoln25 criteria and notice a little more premenstrual syndrome, more than through the Consolidated Criteria for Reporting Qualitative usual’.- P8. Research checklist.26 Reflexivity processes were in place Independent of whether participants had experienced throughout the whole study to ensure the quality of the menstrual alterations, it was common to consider stress as study, a risk factor for menstrual changes: ‘(. . .) The whole thing of changing habits and stress and everything, I think it is super normal, it must have happened to everyone’.–P9. Data analysis However, many participants reported not remembering if Qualitative data were analysed using Thematic Analysis,27 their cycles were different. This lack of awareness among including COVID-19-related data only. First, ASH and some participants was also evident as they appeared LMP carried out preliminary analyses by reading, reflect- to solely focus on menstrual cycle length and disregard ing, and discussing the data. Then, interviews were coded other menstrual characteristics (e.g. bleeding abundance): by ASH and LMP. The coding schema was triangulated ‘I think not, I think I have them registered and I think the between ASH, CJA, and LMP, by discussing codes and cycles were normal . . . Maybe one lasted 42 or 43 days, potential themes/subthemes and sharing analytical inter- but the rest I think were normal .’..–P12. This seemed to pretations. Through a collaborative and reflexive process, indicate that cycle length may be more often used to indi- initial themes and subthemes were then identified between cate menstrual health ‘normality’ rather than, for example, ASH and LMP and discussed with all co-authors until a experiencing dysmenorrhea. final thematic framework was devised. Field notes were Two participants, diagnosed with long COVID-19 (P17 also considered throughout the analysis process. and P23), reported significant menstrual changes since More details on the methods can be found in a previ- getting COVID-19. Both reported longer and irregular ously published article.17 cycles, severe menstrual pain, high menstrual abundance, Holst et al. 5 and menstrual clots. They also described how long On the other hand, P11 mentioned that health education COVID-19 symptoms had a cyclical nature and were programmes (including menstrual education) at schools related to the menstrual cycle, advocating for the need to were stopped during lockdown, suggesting a potential research on long COVID-19 and menstrual alterations: impact on menstrual education and health for girls and young PWM because of the COVID-19 syndemic: well. . . the research teams must consider this (relationship between long COVID-19 symptoms and the menstrual cycle) (. . .) in my clinic and in several clinics in Barcelona, the as well. And, in fact, we (people living with long COVID-19) health program called “Health and School”, nurses from the are emphasizing this a lot, that it (long COVID-19 symptoms) clinics go to talk to the schools about various health issues gets worse when there is the cycle (menstruation) and the fact throughout the course. Now with COVID it is suspended–P11. that most of us (people affected by long COVID-19) are women, it also seems that this (long COVID-19 affecting more women than men) has a bit of a correlation.–P23. COVID-19 lockdown as an opportunity for menstrual self-care and improved menstrual Access to healthcare services and the systemic management disregard of menstrual, sexual and reproductive Participants often considered menstrual management to health be easier since the onset of the syndemic, given that par- ticipants spent significantly more at home and less in Access to healthcare for menstrual, sexual and reproduc- public spaces. P11, who worked as a primary healthcare tive health during the first COVID-19 lockdown was doctor, mentioned the decrease in face-to-face consulta- perceived to be challenging. One participant explained tions as an enabler to change menstrual products more how she only managed to get a healthcare consultation to frequently when menstruating, something she had previ- change her contraceptive implant because she had her ously struggled with due to the high volume of healthcare midwife’s private phone number. Based on her experi- consultations: ences, she perceived the access to private healthcare to be easier, but she did not have the resources to have a private Now with COVID it has changed a lot because there are not health plan. She expressed her fear of an unwanted preg- so many patients in person. But before, there were always nancy if she could not change her implant timely: people in the waiting room, so of course, (. . .) I had to go in front of those people to go to the bathroom and people are Ooh, the truth is that I was trying, calling, calling, calling, and waiting to go in, so they’re nervous.–P11. calling. It was a challenge. Nobody would pick it up and then (. . .) the answering machine (. . .) was full. (. . .) And in the P14 shared a similar experience as she started using end I had to find on my own some way to be able. . . because pads again during the syndemic: I was also very worried. I don’t want to have children. (. . .) So I was worried. I used condoms but also. . . I did not feel I have spent much more time at home or at someone else’s safe. (. . .) If I had private healthcare, it would have been home, in private places and I have even opted for the pad. I something else (laughs). The truth is that in the public haven’t used it for a long time because sometimes you think healthcare system I had a bit of a bad time.–P25. you’re going to be seen or it’s more uncomfortable. And being at home makes it easier to clean.–P14. Furthermore, P17, who was diagnosed with long COVID-19, highlighted not only the difficulties in access- On the other hand, P24, who identified as non-binary, ing healthcare but the prevailing dismissal of menstrual explained how not being in public spaces in his (P24’s health and gynaecological issues related to COVID-19 by preferred pronouns) day-to-day meant that he was not healthcare professionals. She added that she worried about confronted with having to choose whether to manage his the long-term effect of long COVID-19 on fertility, and the menstruation in the men’s or women’s public bathroom, lack of information and responses received in healthcare which would sometimes trigger feelings of gender services. For P24, accessing healthcare services was even dysphoria: more complicated (during COVID-19 and not), given the struggles he had to face regarding his gender identity: Many times I do not have a problem and I go into the first one (bathroom stall) that comes up and I do not care, but depending I feel that we are used to assume people’s gender, assume. . . on the day, if that day I have something like dysphoria or I feel the pronouns they use (. . .) I feel it is super important that we a little more insecure, no matter what happens, yes it is like start having that conversation and normalising the fact that. . . “holy shit, which bathroom represents me, (which bathroom when you present yourself tell them your name, tell them your should) I have to go to?” And then everything is a drama. . . pronouns (. . .) So that it is not a point of, come on I’m going [. . .] it is super important that. . . there are neutral spaces to get all my strength and express my identity in the world, it’s that. . . (. . .) I don’t know. . . the reason why there shouldn’t like fuck, so maybe I don’t feel like it, you know?–P24. be, but yes. . .–P24. 6 Women’s Health Pain management was also described to be more attain- Besides, there were accounts of friends and family able as self-care was more easily available staying at members struggling financially since the syndemic started, home. In line with the improved opportunities for men- and how that could mean for them to experience menstrual strual management and self-care during lockdown, P18 poverty: reported that her relationship with menstruation improved significantly during the syndemic: I have relatives and I have friends . . . who have lost their jobs (. . .) Usually what do people do? People with a little common Honestly, during the pandemic I have experienced the best sense, the products they need, they buy them cheaper. (. . .) menstruation, because it is when I have had the best I’m going to look for them cheaper, even if they are of less relationship with myself, that I have not had to worry about quality (. . .), and if you don’t manage (to buy them), using anything, and let’s say, I have had the best relationship (with (toilet) paper, or making the pads last longer? Of course, the menstruation). But in general, yes, I consider it as . . . I thing is that you will menstruate anyway. Whether you have experience it as an annoying process for me.–P18. money or not (. . .)–P2. However, menstrual management was also challenging Besides, two participants compared the mask mandates in situations in which menstruation had to be managed in during COVID-19 to menstrual products being necessary public spaces. One participant (P30) reported her struggles goods that are not affordable for all. P9 also made a remark finding a public bathroom to change her menstrual product on face masks being mandatory for the whole population, when national lockdown measures were lifted but strict while menstrual products were ‘only’ required by women public health restrictions were still in place (e.g. bars and and PWM: restaurants were closed): If it is something mandatory that I have to wear, that I don’t Oh yes. . . Just recently, when the restaurants were closed and choose, it cannot be something that costs me a lot of money. such, I was with a friend, we were taking a walk and then of And I was thinking, well, why haven’t we thought about course I noticed that I was staining that. . . the pad was no this before? It is exactly the same (with menstrual products). longer holding and I. . . “wow” where can we go now, But the pandemic affects everyone, that’s the difference I everything is closed, the bars are closed, they don’t let anyone think.–P9. in, and I was like “uff”. In the end we had to run to my friend’s house, I had to go upstairs, changing my pad. . . and I had already stained.–P30. Discussion This study explored the experiences of menstrual health and menstrual management among women and PWM in Access and affordability of menstrual products the Barcelona area (Spain) during the COVID-19 syn- demic. Some participants experienced menstrual altera- In general, participants did not report differences in the tions, particularly those diagnosed with long COVID-19, accessibility and affordability of menstrual products dur- while others did not notice any changes. Besides, health- ing the syndemic. Using the menstrual cup, as some par- care access was compromised, and participants shared ticipants did, meant not having the need to buy menstrual experiences of menstrual health concerns being disregarded products during the syndemic. However, living in a small by healthcare professionals. Another important finding is city or rural area made it more challenging to access men- that menstrual management and self-care were generally strual products. Supermarkets did not always sell preferred easier given the reduced exposure to public spaces. menstrual products and mobility restriction during lock- Based on data from previous international study, includ- down prevented the population to access other shops that ing data from 15 countries including Spain, menstrual cycle were further away from their place of residency: indicators changed during the first 6 months of 2020.28 However, some participants in our study did not recall any Maybe, I have gone to look for a specific one and there was menstrual alterations and often perceived their menstrua- none, that maybe yes. But being with no protection like that, no (. . .) Or well, maybe I have noticed it more during the tions as ‘normal’, particularly if they had regular menstrual pandemic, because if, of course, during the pandemic you cycles. The focus on the ‘regularity’ and length of the couldn’t walk to many supermarkets either, you had to go to menstrual cycle rather than their lived experiences (such as one and you would have to manage, then it was like I did not fatigue or pain), could suggest a lack of menstrual aware- have other opportunities to enter other supermarkets to find ness and body literacy18,29,30 and the general neglect of sub- what I was looking for.–P26. jective menstrual experiences. It can also be explained through how menstruation is usually conceptualized socially In order to avoid having to shop often, and due to fear and reduced to a biomedical perspective, relegated to sexual of shortages during lockdown, one participant reported and reproductive health.18,31 Overall, this could mean that buying larger quantities of menstrual products than usual menstrual alterations may have remained unnoticed unless (P16). they were very obvious and persistent, and consistent with a Holst et al. 7 biomedical framework on menstruation and the menstrual face to face consultations during lockdown, potentially cycle. aggravated health inequities among populations affected Consistently with available published research,12,15 by the digital divide.39 Despite the COVID-19 syndemic stress was mentioned by participants as a risk factor for may have magnified the barriers to healthcare access, it is menstrual health during COVID-19. The syndemic has important to acknowledge that these were already preva- come with multiple possible stressors, from fear of infec- lent prior to the syndemic, including for menstrual health.18 tion, and fear of loved ones having COVID-19 or being In this study, participants generally reported menstrual hospitalized, to losing jobs and livelihoods, having chil- management to be easier during the COVID-19 lockdown. dren at home because of school lockdown, caring for This was reported to be due to an easier access to adequate dependent people, not being able to leave home and con- menstrual management spaces during lockdown, more tinue with your normal life, increased strains in relation- opportunities to menstrual self-care, including for pain ships, increased experiences of gender-based violence.32,33 management. In essence, having access to a menstrual- These strains might very well be linked to menstrual alter- friendly environment. This was only possible as the syn- ations experienced by some participants.11 demic meant life, and consequently menstrual management, Findings from the ‘Equity and Menstrual Health in happened almost exclusively in private spaces (i.e. their Spain’ project suggest that long COVID-19 diagnosis is a homes) for most women and PWM. Not having to manage risk factor for reporting menstrual alterations.11 This is menstruation in public defused common challenges such consistent with the experiences shared by two participants as the access to adequate menstrual management spaces, in this qualitative research, who reported menstrual altera- and experiencing menstrual taboo, stigma and discrimina- tions since getting COVID-19. Moreover, they shared their tion,18,40–42 including for gender non-conforming menstru- experiences on the systemic neglect of menstrual health in ators. While menstrual management was easier when was healthcare services, with healthcare professionals often relegated to private spaces,18,19,43 it became challenging dismissing the menstrual alterations they experienced. when lockdown measures started to lift but closures of, for This could point to healthcare professionals not acknow­ instance, bars and restaurants impeded the access to bath- ledging menstruation and the menstrual cycle as vital sign room in public spaces. Our findings differ from previous of health,34 which directly points out to the prevalent research including the experiences of vulnerable popula- androcentric views and the continuous neglect of gender in tions, such as women and PWM in situations of homeless- health research and practice.18,35,36 However, even if highly ness19 or living in contexts with impaired access to water, strained, sexual and reproductive healthcare centres in sanitation, and hygiene (WASH).44 This can be explained Catalonia stayed opened throughout the syndemic. Thus, as participants in our study lived in stable housing and the lack of response from healthcare professionals could were generally not living in situations of socioeconomic also be the result of healthcare system being under pres- deprivation. It also reinforces the need to further research sure, not being able to prioritize menstrual health. Besides, on how social and health crises may deepen intersecting healthcare professionals may have not had enough time, social inequities of health, based on sociohistorical oppres- material, and informational resources to address menstrual sions, for instance and particularly on women. While the health consultations at the start of the COVID-19 syn- COVID-19 syndemic has been established as a crisis of demic, partly as professionals also lacked knowledge to care,45 making the negative impact of neoliberal politics address COVID-19 and its impact on the populations’ on social reproduction (a term referring to self-care and health. Through our research, participants claimed for care for others, including healthcare) bare, our findings more research on the impact and management of long highlight that menstrual self-care may have been facili- COVID-19, especially regarding menstrual health consid- tated when housing and socioeconomic conditions were ering that more women are affected by long COVID-19.37 adequate. As previously discussed, this relates to the Healthcare professionals should also be given support to repercussions menstruating in public has on women and access necessary resources to address menstrual health. PWM,40,41 and points towards the need to create safe men- Nonetheless, participants generally reported not strual spaces in public spheres as enabling menstrual self- having attempted accessing healthcare. Those who had, care is imperative to menstrual health and equity. reported barriers receiving non-COVID-19-related health- Experiences of menstrual poverty, which refers to care.11 A general reduction in utilization of healthcare financial barriers to access menstrual products,18,46,47 were services has been across the world during the initial lock- shared by participants in our research.18 Access to men- down,6 with vulnerable populations having a higher risk strual products during lockdown was mentioned to be for unwanted pregnancies and unsafe abortions due to challenging, particularly based on product availability in healthcare restrictions.38 An explanation could be due to shops that were within the are participants could commute the populations’ fear of contracting COVID-19 when uti- to. Strict mobility restrictions in Spain, which prevented lizing both public and private healthcare services. the population from moving beyond a few metres from Furthermore, the use of digital health solutions such as their place of residency, were also mentioned to constrain telemedicine, which started to be implemented to avoid accessibility given that participants could not travel to 8 Women’s Health alternative shops to buy their preferred menstrual prod- women and PWM experienced menstrual changes since the ucts. Interestingly, participants did not mention buying start of the syndemic, especially those living with long menstrual products online, potentially as online shopping COVID-19, participants expressed how access to health- infrastructures were not as established at the start of the care services was highly impaired and menstrual health syndemic. This was slightly more difficult in rural areas. consultations were sometimes disregarded. Considering These limitations in accessing menstrual products are con- that women and PWM in our study had access to stable sistent with previous research in Spain, which indicate that housing and did not experience situations of severe socio- over 2 in 10 women and PWM had difficulties accessing economic deprivation, menstrual management and self- menstrual products during the syndemic.11 Evidence in care were mentioned to be facilitated during lockdown. other countries21,20 also supports these findings, especially This was due to the relegation of menstrual management to in contexts where access to WASH has also been burdened the private sphere and the consequent decreased exposure during the syndemic.48 For this reason, reusable products to barriers for menstrual management in public spaces, and such as the menstrual cup may have facilitated menstrual to menstrual stigma and discrimination. Restrictions to management during lockdown.49 Further research is access menstrual products, due to mobility restrictions and needed to explore accessibility of menstrual products and products’ availability, were also mentioned. Although more menstrual poverty (including price regulations) among research is needed to widen the overview of menstrual vulnerable populations, and particularly those who were experiences, especially among socioeconomically vulnera- highly burdened the economic impact of the syndemic or ble women and PWM, our findings support the need to that were already in socioeconomic vulnerable contexts address menstrual health and inequity, particularly in times prior to the syndemic.20 Besides, some participants referred of social and health crises. Further research is required to to the public complaints that arose when facemask for deepen the evidence on the impact of the COVID-19 syn- COVID-19 prevention were made mandatory, given the demic on menstrual health and menstrual equity to ensure economic cost facemasks had. They compared this public syndemic preparedness. Research should be conducted debate with the lack of public discussions in Spain around alongside policies that ensure the access to healthcare ser- the need for menstrual products’ price regulations and vices, menstrual management and self-care in public set- accessibility issues, even if they are necessary goods for tings, and menstrual products. These policies should be half the population (regardless of a syndemic). This again far-reaching, allow women and PWM to actively make may underline the structural neglect of women, PWM and informed choices, and adapted to the needs of different menstruation, and the historical lack of attention towards population groups, to effectively address core determinants menstrual needs.41 of menstrual health and equity. Social determinants of health and intersectional gender-based approaches should be imperative in both research and policy efforts, ensuring Limitations women and PWM actively participate and lead both Several limitations to this research should be considered. research and policymaking. Most participants had completed high education and lived in stable housing; thus, our results may not be illustrative Declarations of the experiences of socioeconomically deprived women and PWM, who may have been more impacted by the Ethics approval and consent to participate COVID-19 syndemic. Besides, recruitment and data col- Approvals from the Institut Universitari d’Investigació en lection may have been compromised given that they were Atenció Primària Jordi Gol i Gurina (IDIAP Jordi Gol) Ethics mainly done online due to COVID-19 restrictions at the Committee were obtained on 21 November 2020 (Ref 19/178-P). time of the research. Potential participants affected by the All participants were informed of the study and gave their oral digital divide may have encountered barriers to participate. and written consent to take part in the interviews. Verbal consent was obtained to ensure consent to participate right before starting Despite non-binary PWM took part in the study, accounts the interviews and starting the audio recordings. Also, to build in this publication do not include an exhaustive representa- rapport with participants. Data have been stored safely to ensure tion of the diverse experiences of non-binary, trans, and participants’ anonymity and confidentiality. intersex PWM. Finally, participants interviewed at sexual and reproductive health centred may have felt restrained to Consent for publication share negative healthcare experiences, which could have All participants gave their written consent to publish their compromised the exploration of healthcare-related issues. anonymised data. Author contribution(s) Conclusions Anna Sofie Holst: Conceptualization, Formal analysis, Investi­ This study highlights the experiences of menstrual health gation, Writing – original draft. and management among women and PWM in the Barcelona Constanza Jacques-Aviñó: Conceptualization, Formal analysis, area (Spain) during the COVID-19 syndemic. While some Methodology, Writing – review & editing. Holst et al. 9 Anna Berenguera: Conceptualization, Formal analysis, Funding Jordina Munrós-Feliu https://orcid.org/0000-0001-6663- acquisition, Resources, Writing – review & editing. 0943 Cristina Martínez-Bueno: Conceptualization, Formal analysis, Diana Pinzón-Sanabria https://orcid.org/0000-0002-8163- Resources, Writing – review & editing. 7825 Jordina Munrós-Feliu: Conceptualization, Formal analysis, Laura Medina-Perucha https://orcid.org/0000-0002-2981- Writing – review & editing. 2614 Diana Pinzón-Sanabria: Conceptualization, Formal analysis, Writing – review & editing. Supplemental material Carme Valls-Llobet: Conceptualization, Formal analysis, Writing – review & editing. Supplemental material for this article is available online. Tomàs López-Jiménez: Conceptualization, Formal analysis, Writing – review & editing. References Andrea García-Egea: Conceptualization, Formal analysis, 1. Caron RM and Adegboye ARA. 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