Capturing menstrual health and hygiene in national surveys: insights from performance monitoring and accountability 2020 resident enumerators in Niamey, Niger

Menstrual health and hygiene (MHH) is an emerging public health priority. To support policy and practice, large-scale surveys monitoring water, sanitation, and hygiene and reproductive health have started to incorporate MHH. Insights gained from these surveys are contingent on the quality of the measures used. Performance Monitoring and Accountability 2020 (PMA2020) was one of the first survey programs to include MHH. We undertook four focus group discussions with resident enumerators and one with their female supervisors following the 2018 PMA2020 survey in Niamey, Niger and synthesized their insights on the performance of the MHH measures used. Enumerators reported that questions about menstruation were well tolerated and most were understood conceptually. Discussions identified missing response options for the places used for MHH and suggest that enumerator training should include common brands of menstrual materials to ensure data quality. Further, current questions seeking to capture the privacy and safety of locations used for MHH require modification or more intensive training efforts to consistently capture these concepts. Enumerator perspectives on menstrual needs in Niger highlight topics missing from MHH monitoring. Attending to enumerator expertise has the capacity to strengthen future surveys directed toward understudied health and development challenges such as MHH.


INTRODUCTION
UNICEF ). As such, the field has developed measures in parallel to implementation, presenting limited opportunity for review. To ensure measures meaningfully capture MHH, we must continue to reevaluate and refine.
The present study PMA2020 launched to monitor reproductive health outcomes in LMICs (Zimmerman et al. ). The program relies on a cadre of female resident enumerators (REs) in 11 countries who administer household and health facility surveys. PMA2020 recruits REs from sampled communities.
Over time, enumerators become experts in their survey area, making them valuable contributors in the effort to understand how PMA2020 survey measures perform (Greenleaf et al. in press).

PMA2018-Niger
PMA2018-Niger used a two-stage cluster design with primary sampling units (PSUs) selected using probability proportional to size. Thirty-five households were selected randomly from each cluster, and all women aged 15-49 years in sampled households were eligible to participate in the female survey. Additional information about PMA2020 methods is available elsewhere (Zimmerman et al. ).

MHH in PMA2020
The PMA2020 survey collects data on reproductive health indicators; water, sanitation, and hygiene; and MHH.  Table 1.

Focus group discussions
Thirty-three REs collected data for the PMA2018-Niger survey. Each conducted at least 25 female interviews. All REs were invited to participate in the focus group discussions (FGDs) following data collection. A total of 20 REs (60.6%) and 2 female supervisors participated in the qualitative study. REs were split across four FGDs by age (20-30 years; 31-49 years) and marital status (married; unmarried). A fifth FGD was conducted with the two supervisors. Six REs were never married and under 30 years old, five were over age 30 and single or divorced, and nine were over age 30 and married.

Analysis
To contextualize RE and supervisor feedback, we provide a descriptive summary of the PMA2018-Niger MHH data.
Presented descriptives are adjusted for sample design. RE and supervisor feedback are presented for each PMA2020 question as a thematic summary. We thematically analyzed field team reflections on women's experiences of menstruation and recommendations for topics not covered in the PMA2020 survey.

Feedback on the performance of MHH questions
Below we present enumerator feedback on MHH questions following the order outlined in Table 1.  Acceptability While acknowledging that menstruation was a sensitive 'women's issue', REs reported that overall, MHH questions were acceptable and women readily answered. REs noted MHH questions were less challenging than those related to sexual practices which were the most challenging for gaining trust and responses.

Location for MHH (001a)
Field staff generally agreed that the question capturing the place used for changing menstrual materials was easy for respondents to understand. Some did describe, however, needing more time to clarify when women reported separate locations for cleaning and changing: '… They try and tell me they use an outside toilet to clean themselves. But that they need to go into their room to get a new sanitary napkin. But to remove and throw away the old one, that is usually done in the toilet, and then the new one is put on in the bedroom.' (FG4) REs noted the most common responses were sanitation facilities, bedrooms, or bathrooms. Notably, a bathroom/ shower room does not appear as a response option in the PMA2020 surveys, which had been raised as an issue during data collection.
In past PMA surveys, response options included the general household sanitation facility or another sanitation facility. In 2018, the survey asked respondents to specify the type of facility. REs reported that this did not cause difficulties because they had ascertained the facility type during household surveys.

Characteristics of MHH location (001b)
When describing the primary location for managing men-

MHH materials (002)
REs noted that Niamey women's use of menstrual materials was driven by their economic status. Generally, REs and supervisors thought women responded easily to this question. REs stated that women using commercial products would often respond with the brand name. One RE noted that some participants experienced embarrassment around the use of atypical materials: 'There was one woman who … wanted to know why I was asking that question. It wasn't easy for her to answer. It was only then that she told me she uses [another material] because she doesn't trust sanitary pads. So, she didn't answer me directly, because she wasn't comfortable giving me her answer, but told me by way of explanation that that was what she used.' (FG4) She is scared of getting stained in front of her schoolmates, so she misses school.' (FG2)

Field team perspectives on MHH needs
REs did not express strong views regarding questions that should be added to capture women's menstrual experiences.
However, at the start of the FGD when discussing women's experiences and worries, they articulated MHH needs not captured in surveys. Field staff noted the financial burden of accessing menstrual materials and raised issues related to menstrual pain, both in terms of pain-related challenges and the need for improved access to pain relief options.
REs noted concerns about irregular cycles, with irregular periods causing stress if menstruation starts without warning. Many REs discussed challenges women faced managing menstruation when traveling outside the home, such as in markets and on public transport, and challenges finding private spaces to change materials and self-cleaning.
Particularly, this was challenging in the context of concealing menstruation. All FGDs emphasized the stigma associated with menstruation. Groups discussed that this led to discomfort and anxiety among women.  and should be prioritized for inclusion in monitoring efforts.

Strengths and limitations
PMA2020's REs provided important insights to refine measures used to monitor MHH. This study would have benefited from in-depth interviews and cognitive interviewing with respondents.

MHH remains a nascent topic for public health research in
LMICs. Our findings suggest that attention to question