Title: “Sometimes I just forget them”: Capturing Experiences of Women about Free Menstrual
Products in a U.S. Based Public University Campus
Version: 1 Date: 11 Mar 2023
Reviewer's report:
Feedback on manuscript
Overall: I think this paper provides important insights on university students' experiences
with free menstrual product policies. There remains very little evidence on this population's
experiences and university students continue to be overlooked in state-level school focused
menstrual equity policies being introduced across the US. I do have some concerns about
the impact of COVID closures on students' ability to accurately recall their awareness of the
dispensers (and the policy) given they had been off campus for a substantial amount of time
(6 months or more) when data collection occurred. I also don't think that such limitations are
effectively addressed in the manuscript at present.
Introduction:
The introduction provides a overview of the current policy landscape of the menstrual equity
movement. It is however missing many important updated citations and accurate descriptions of
the current policy landscape in the US. A few suggestions for improvements have been provided
below:
1. I think it is missing that there is growing research exploring the impact and prevalence of
period poverty on US students in middle and secondary schools. Lesser research has been done
exploring university students’ experiences, which validates the importance of this study. I would
more effectively highlight this gap and cite the existing literature.
Possible citations:
• https://pubmed.ncbi.nlm.nih.gov/34962178/
• https://journals.sagepub.com/doi/full/10.1177/07435584221139342
• https://www.tandfonline.com/doi/full/10.1080/02673843.2020.1867207
• https://www.jahonline.org/article/S1054-139X(20)30296-2/fulltext
• https://journals.sagepub.com/doi/10.1177/1059840520974234
2. Last paragraph on page three: I would suggest adding a few updated citations to this paragraph
as there has been updated empirical research conducted on homelessness and emergency
planning including the following:
Possible citations (there are likely more than this):
• Homeless populations: https://pubmed.ncbi.nlm.nih.gov/33849575/
• US Emergency Response Planning: https://kuscholarworks.ku.edu/handle/1808/32180
3. I think the last paragraph on page 3 fails to account for the number of US states that have passed
legislation providing menstrual products to students. Numerous states that have passed some
sort of legislation and that needs to be noted. Some of these states include public universities in
their policies and should be described as well given the focus of this manuscript (for example
CA and IL).
a. CA: https://msmagazine.com/2022/02/25/the-period-project-menstrual-equity-free-pads-
tampons-schools/
b. IL:  https://www.sj-r.com/story/news/2021/05/25/illinois-senate-backs-free-menstrual-
products-public-colleges/7432112002/
This Marie Claire article by Jennifer Weiss Wolfe highlights some of these policy updates and
has citations: https://www.marieclaire.com/politics/a35280718/menstrual-equity-2021-goals/
• “In recent years, six states (https://www.periodequity.org/period-equity-aclu) have mandated
that pads and tampons be provided in schools, and 13 states (https://www.periodequity.org/
period-equity-aclu) passed laws to require them in prisons, jails, and shelters. Many cities and
communities have done the same, even extending to places like public benefits offices, libraries,
and parks.”
Currently more than 6 states have passed legislation focused on schools (this is already dated as
it was written in 2021) and I would suggest doing an updated review of the legislation to depict
the current situation more accurately.
4. Furthermore, I’d removed the phasing “However, several policies have been discussed in
the legislation to combat this issue [12]” (page 3, paragraph 3) as there has been far more than
discussions on policies given the substantial growth in legislation being introduced and passed.
Citations to review:
o https://msmagazine.com/2022/02/25/the-period-project-menstrual-equity-free-pads-
tampons-schools/
o https://www.sj-r.com/story/news/2021/05/25/illinois-senate-backs-free-menstrual-products-
public-colleges/7432112002/
o https://msmagazine.com/2022/02/24/period-project-menstrual-equity-women-prisons/
o https://www.frontiersin.org/articles/10.3389/frph.2021.725805/full
5. Given that this study was conducted during COVID, I would suggest adding a new paragraph
describing how period poverty was exacerbated during the pandemic. This includes students
who depended on schools for menstrual products being unable to access them as easily.
Citations to review:
• https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306674
• https://cdn.shopify.com/s/files/1/0795/1599/files/State-of-the-Period-white-
paper_Thinx_PERIOD.pdf?455788
• https://thepadproject.org/menstrual-products-school-districts-and-covid-19/
6. Page 4, third paragraph: I would suggest adding more details about your university’s policy,
including the actual policy text. Does the policy just refer to providing free products or does it
specify HOW those products are distributed (e.g., inside female and gender-neutral bathrooms)?
Did it include the installation of dispensers (and disposal bins) or just products? What was the
motivation for the policy? For example, was it student led or administration led? Also, when
exactly was the policy enacted (how many months was it in operation before COVID closures?).
These details all feel relevant to framing the study.
7. Page 5, first paragraph: You might want to consider that another goal of the research is
to support legislative efforts to pass policies which are inclusive to public universities as the
majority prioritize middle and secondary schools.
8. Page 5, Social-Cultural Implications: Per this sentence: While views about menstruation
vary widely across cultures [16–23], health and social science experts worldwide recognize
menstruation management as a global public health issue exaggerated by social stigma,
misinformation, and structural barriers [15, 20, 24–27], the effects of which can exacerbate
medical issues [28, 29]. I wouldn’t assume the reader knows what medical issues you are
referring to. Can you provide more detail?
9. Page 6, first paragraph: There is an absence of consideration of the role bathrooms on
menstrual experiences. I would suggest adding some acknowledgement that a menstrual
experience is shaped by not only cultural beliefs and access to products but also the availability
of supportive facilities for accessing or changing these products. This includes toilets with
accessible waste receptacles and dispensers. The latter is especially important given it’s a finding
in your paper.
a. https://journals.sagepub.com/doi/full/10.1177/07435584221139342
b. https://swhr.org/survey-of-school-nurses-reveals-lack-of-bathroom-policies-and-bladder-
health-education/
c. https://journals.sagepub.com/doi/10.1177/0959353512473812
10. I would suggest moving up the “Free Menstrual Management Product Policies and High-
Income Countries” section as there is a disconnect between the page 3, paragraph 3 which
frames that there are very few policy developments taking place in the US (which isn’t the
case). I also think the policy summary isn’t considering the state-level policy developments
sufficiently (highlighted above), which is especially relevant given the study takes place at a
public state university (right?). I would recommend updating the policy summary to include the
most up-to-date policy developments focused on schools and highlight that only a few of these
policies include universities (again, I don’t know the specifics on numbers, but I’d recommend
identifying this as it highlights the importance of this study).
Methods:
The methods provide a good overview of the design, conduct and analysis used in the study.
A few suggestions include:
1. Setting: Can you provide more details on the university where this study took place? For
example, public or private? Size of student body? Percentage of students that live on campus
vs. commuters? Has state of the university enacted any menstrual policies?
2. Participant Recruitment: I would suggest providing more details about the sample if possible.
Was any demographic data collected? For example, the age breakdown, race/ethnicity, academic
year (e.g., amount of time on campus), gender identity, SES?
3. Virtual Focus Groups: There is only a slight mention to the product testing activity here despite
it being referenced elsewhere in the study (e.g. discussion). Add some detail about how this was
designed/conducted and how that component interacts with this study. Also please add details
on who specifically conducted the FGDs (previous qualitative experience? Trainings?).
Findings:
1. A few general suggestions for the findings section:
• Do not start a new thematic section (or paragraph) with a quotation but rather adding a sentence
or two framing it first.
• Double check the capitalization of quotations inserted directly into paragraphs (several are
capitalized when they should not be).
• Do not conclude a paragraph with a quotation either. There needs to be sentence providing
some sort of contextual finding or summary of the learning after every quotation shared.
• Can you italicize all quotes so it more obvious where they are inserted?
2. For finding two “the need for appropriate products for comfort”:
• I’d suggest defining what “quality products” means for the reader? For example, the thickness,
absorption capacity, specific brands, etc.
• Would rephrase this: This begs the question, who should be making the product decisions for
purchase?
• I would be more specific about this finding: “Other participants shared similar sentiments
preferring that educated and experienced people make these purchase decisions.” For example,
“other participants shared similar sentiments preferring that product procurement decision were
made by individuals with direct menstrual experience and familiarity with the range of product
options available.”
Discussion:
A few revisions have been detailed below:
1. Paragraph 1: Add more detail to this sentence: “Through the focus groups, we identified
that students felt strongly about access to free products and policy implementation and reported
broader cultural impacts of access to free products in their university.” Specify what “felt
strongly” means. Positive or negative? Felt strongly on the importance of access?
2. Paragraph 1: Suggest rephrasing this: "Participants provided significant insight on improving
the program and discussed broader implications of a free period product policy at a community
level." The wording isn’t right here, perhaps modify to something like this “participants provided
insights into some ways the current menstrual product program could be improved moving
forward…”
3. Paragraph 2: Per this sentence: “However, the lockdown also provided an opportunity for the
researchers to conduct product testing with locally residing volunteers which led to valuable
information.” Is this learning going to made available in a forthcoming publication? You need
additional context on this as it is not well-described in the study design. Also, I would better
highlight WHY additional consultation on product types is valuable (e.g., the diversity of
personal preferences on menstrual product types and brands). This study indicated a diversity
of opinions and I think that needs to be illuminated here. You may want to also cite some of
the literature which backs this up.
4. Paragraph 3: Per this finding “First, participants expressed apprehension about using the
product dispensers due to negative past experiences, emphasizing the importance of spreading
awareness of the modified dispensers as well as dispenser sanitation and upkeep.” I find it this
sentence confusing. What do you mean by “negative experiences” and how is that supported
by the data you’ve shared in the findings? Also, where is “dispenser sanitation and upkeep”
highlighted in the findings? It’s an important piece but I don’t’ see it effectively showcased in the
findings section. I think this paragraph of the discussion needs to dig a bit deeper into dispenser
design, aging infrastructure, and the actual placement of the dispensers. A few suggestion
citations to review:
• https://www.wsj.com/articles/tampon-dispensers-lack-that-high-tech-wow-
factor-11556800479?reflink=desktopwebshare_permalink
• https://www.wusa9.com/article/news/hooha-smart-tampon-dispenser-looks-to-solve-old-
problem/65-fd182997-0573-45b6-8690-d56982c22b3f
• https://www.frontiersin.org/articles/10.3389/frph.2021.725805/full#B37
5. Paragraph 4: I think this paragraph is missing any mention to the budgetary concerns of
universities when introducing these new policies, which was one of the most important findings
of the Gruer study. This includes the recommendation that more costing related research is
conducted at universities to mitigate some of the budgetary related concerns (in addition to
worries about the hording of products, which is a common concern for nearly all free product
policies and initiative). Also, it would be useful to know the motivation of your university
in providing products. The Gruer article notes that providing products “in the case of an
emergency” was the objective several universities. Is that the case of your university? If that is
the objective, it may have implications on the placement of these products.
6. General: I think adding a paragraph about the finding on student concerns regarding the
environmental implications of menstrual waste could be useful, especially given the rise of eco-
friendly menstrual products options and advocacy. This also lends itself to the discussion on
menstrual product personal choice you are already highlight.
Example citations:
• https://www.mdpi.com/2071-1050/11/2/473
• https://www.nytimes.com/2022/01/20/well/sustainable-period-products.html
• https://iwaponline.com/washdev/article/13/2/63/93386
Implications:
1. General: This section does not place this study within the larger policy landscape. More
evidence on university student’s experiences with menstruation and the value of free menstrual
products can serve as a useful resource to policymakers trying to make state-level legislative
change. It specifically highlights how public universities shouldn’t be left out of the state-level
school policies, right? It can also be used for other universities seeking to replicate such efforts
at new campuses.  I would add an entire paragraph just on the potential policy implications.
2. Paragraph 2: Per this sentence: “For dispensers to appear safe and reliable to users, dispensers
must be properly maintained and restocked.” I am unclear on how dispensers are perceived
as unsafe? What are the dangers associated with dispensers? Highlight this safety issue in the
findings or suggest rephrasing.
Strengths and Limitations:
1. Per this sentence: “Thirty-two participants came from diverse backgrounds, leading to
many perspectives and insights into menstruation management in other cultures.” This is not
highlighted in the methods section. Provide additional details on the sample (race, ethnicity,
gender identity) or would rephrase/remove. Also, what does diverse actually mean? There are
lots of interpretations of that word.
2. Might suggest using a more expansive terms such as students identifying as “transgender and
non-binary” as opposed to “transgendered communities.”
3. I would highlight that COVID and associated policies/closures was a key limitation in
this study as students experiences on campus had massively shifted which could have had
implications on student awareness of the policy and existing product distribution sites. It also
could have implications on student access.
4. Given that students had not been on campus for months, there is high likelihood that students
experience recall bias in terms of remembering where and when free products were located. I
would definitely highlight this as a limitation to the study.
5. If you didn’t collect any information on SES, you could also mention that further evaluation
may be needed specifically on low-income students’ experience, especially given the Cardoso
study which highlighted that low-income students experience higher rates of period poverty.
I think this paper requires extensive revisions to the format and a more thorough review of the
existing evidence base on menstrual policies and developments. The latter exercise should be
integrated into both the introduction and discussion sections.