Just 4U™: Reusable Period Pants Alongside an Ovulatory Menstrual Health Literacy Program

Abstract

The concept of “period poverty” describes the lack of access to menstrual health education and menstrual care products. This quasi-experimental mixed-methods study evaluated a collaboration called Just 4U™ to address period poverty. This collaboration was formed between My Vital Cycles^®, as the provider of educational content, and Modibodi^®, as the provider of period pants as a reusable menstrual product (RMP). Five co-educational schools, including a regional school, participated and were of average to below-average socio-educational advantage ranking in Australia. The pre- and post-intervention evaluation with 63 postmenarcheal adolescents (14–18-year-old) in Grades 9–12 showed an improvement in their ovulatory menstrual health literacy. Open-ended questions explored their perspectives on the RMP. Overall, the RMP was well received by participants, who reported a positive impact on their mindset and cycle management. School staff (n = 6) who had observed delivery of Just 4U™ were interviewed. They believed the program had benefited the participants and recommended that teacher training would help the intervention to be sustainably implemented in schools. Findings highlight the worthwhile inclusion of RMPs alongside ovulatory menstrual health education. This study contributes to ongoing research in adolescent ovulatory menstrual health education.

1. Introduction

Menstrual health is not merely the absence of disease but rather a holistic physical, mental, and social well-being in relation to the cycle [1]. Menstruation has been called a vital sign by the American College of Obstetricians and Gynecologists [2], indicating its integral role in a woman’s life, yet the literature reports the phenomenon of “period poverty”. Globally, this describes the lack of access to menstrual health education and products due to feelings of shame surrounding menstruation and/or the economic burdens of menstrual hygiene management [3].

For adolescents, these challenges are compounded by menstrual health difficulties that they may experience as they begin their menstrual journey. For example, a systematic literature review of 38 studies from low-, middle-, and high-income countries found a high prevalence of dysmenorrhea (71%) amongst 21,573 young women irrespective of the country’s economic status [4]. Such difficulties have been associated with school absenteeism [4] and decreased quality of life [5]. Despite this, research suggests that adolescents are hesitant to seek medical advice [6], and their functional ovulatory menstrual health literacy is low [7].

Menstrual health education has repeatedly been identified as a key strategy to improve health outcomes, such as pain management or premenstrual symptoms [7,8,9]. Furthermore, addressing knowledge, attitudes, and skills through school health education may improve individual health and well-being [10].

The Health Outcome Model is a framework that describes the acquisition of health literacy as a key outcome of education [11]. It comprises three domains: Functional, regarding factual knowledge; Interactive, encompassing skills and motivation to determine or seek good health; and Critical, which involves developing skills for individual action [11]. Within this context, ovulatory menstrual health literacy has been defined as: “Firstly, the discipline of applying ovulatory menstrual cycle knowledge and skills to monitor personal health and manage fertility with due cognizance of life stage and/or stressors; and secondly, confident engagement and active involvement with healthcare providers to maintain and/or restore good health” [12].

However, in school-based ovulatory menstrual health education, this discipline is not routinely taught [9]. Since adolescents are developing and their ovulatory patterns are maturing, understanding the cycle at this life stage presents a unique challenge because individuals have differing experiences [13]. Having ovulatory menstrual health literacy may help adolescents understand their cycles better and prompt them to seek care to restore good health if they experience menstrual difficulties [14]. Furthermore, this specific health literacy may then enable them to successfully navigate their cycles throughout their reproductive lifetime [15].

My Vital Cycles^® is a holistic ovulatory menstrual health literacy program that was developed in response to this need [12,16,17]. Its trial in an independent (i.e., privately funded) single-sex school in metropolitan Western Australia demonstrated its effectiveness in improving ovulatory menstrual health literacy [16]. Recommendations for its future trials included exploring its implementation in co-educational schools [16]. Translation into these schools is valuable, as 93% of independent schools in Western Australia are co-educational [18].

Regarding menstrual products, it has been noted that in high-income countries (HICs), socio-economic disparities can reduce access to products, and menstrual health is a stigmatized topic [19]. Reusable menstrual products (RMPs) are becoming a popular choice for young women in Australia who appreciate their environmental benefits and user-friendly aspects [20]. However, these products are often unattainable because of their initial expense [20,21]. The use of RMPs in HICs has been identified as an emerging area of research [21]. Modibodi^® is an Australian provider of RMPs in the form of period pants. These are rigorously tested to validate functions such as absorbency and breathability while ensuring they are leak-proof for 100 washes and are manufactured free from harmful substances [22].

In 2022, My Vital Cycles^® and Modibodi^® collaborated to address period poverty. This joint initiative was called Just 4U™, named accordingly to emphasize the uniqueness of cycle experiences. It combined core-learning lessons from My Vital Cycles^® to enable girls to understand their own unique cycles with a personally sized order of an RMP from Modibodi^®. It was designed to be implemented with Grade 9–12 menstruant students in co-educational schools.

This study aimed to evaluate Just 4U™ by measuring its impact on ovulatory menstrual health literacy in co-educational schools; understanding the effect of including RMPs alongside education; and exploring school staff perspectives on its utility and implementation. Findings may inform ongoing research into ovulatory menstrual health education and the inclusion of RMPs in education.

Throughout this article, terms such as women/men, girls/boys, and females/males are used in relation to sex (i.e., biological characteristics or reproductive organs). These may differ from gender identity.

2. Materials and Methods

2.1. Study Design

Between February and December 2022, the Just 4U™ program was piloted as a quasi-experimental study. It began with an intervention phase of students’ pre-post evaluation of Just 4U™, which was delivered across two school terms (approximately three months). This allowed sufficient time for the participants to use the RMPs and maintain participant engagement. The post-intervention phase of interviewing school staff began after Just 4U™ had been delivered.

Modibodi^® donated their RMPs but were not involved with the collection, analysis, or reporting of data. Ethics approval from the Curtin University Human Research Ethics Committee was received prior to conducting this trial (HREC2018-0101-10). To protect privacy and confidentiality, a data management plan was provided that described data de-identification, analyses, and storage of all information on a secure research drive accessible only to the research team.

2.2. Participants and Setting

2.2.1. Schools

Convenience sampling was used to recruit schools. Fourteen schools were invited to participate, and five schools provided consent. Only independent schools were approached, in light of delays previously experienced in receiving site approval for public schools [23]. In an effort to address period poverty, the schools approached were of average (1000, SD 100) or below-average Index of Community Socio-Educational Advantage (ICSEA), which enables a fair and meaningful comparisons between schools on the basis of the performance of their students in Australia’s standardized literacy and numeracy testing [24]. Principals provided written consent for their schools to participate.

2.2.2. Intervention Phase (Students’ Evaluation)

Students were invited to participate if they were in Grade 9–12. Inclusion criteria were that they had reached menarche (first bleed) and completed the pre-intervention questionnaire. Participant information statements detailing the study and participation were emailed to each school. Invitations to participate were circulated to families by school staff via email and hard-copy handouts in class. After informed written parental consent and student assent were received, school staff forwarded the online links to the questionnaires to participating students. Students self-reported menarche.

The sample size was calculated using G-Power (Version 3.1.9.7). For 80% power with effect size of 0.5 and participant retention of 60%, it required 81 pre-test and 54 post-test results. This calculation is similar to previous studies [16,25]. The pre-intervention questionnaire was completed by 96 students and the post-intervention questionnaire by 63 students.

2.2.3. Post-Intervention Phase (School Staff Interviews)

Participant information statements detailing the study and participant requirements were provided to staff. The study was explained in an online meeting at their convenience, detailing their involvement. Staff who had observed at least one lesson were invited to an interview post-intervention, aiming for at least one staff member from each school. Staff gave written consent to assist in implementing the trial and to participate in an interview after program delivery. Fourteen staff members were recruited to implement the program, six of whom participated in an interview.

2.3. Piloted Intervention of Just 4U™

The Just 4U™ program consisted of four 45-min sessions delivered every third week by a member of the research team. Each school determined how the Just 4U™ sessions were to be delivered, either (a) during lunchtime or (b) in separate classes, by taking participants out of lessons (e.g., Health Education) or schoolhouse activity time, which is an allotted time for students to work together for sports and other activities in houses or factions. For each Just 4U™ session, at least one school staff member was present.

The first three sessions were lessons from My Vital Cycles^®, which were:

(1)

“What’s healthy?”, in which factual cycle knowledge was taught as functional ovulatory menstrual literacy. Student journals containing all lessons from the complete My Vital Cycles^® program were distributed. Personally sized RMPs were collected by participants with instructions for their use and care;

(2)

“What’s not healthy?”, in which period pain, mood disturbances, iron deficiency, and abnormal uterine bleeds were addressed, and skills to determine good health and seek healthcare confidently were taught as interactive ovulatory menstrual health literacy; and

(3)

“Caring for My Vital Cycles^®”, in which skills to pursue a healthy lifestyle using evidence-based remedies were taught as critical ovulatory menstrual health literacy.

The final session was for students to complete the post-intervention questionnaire.

2.4. Data Collection

2.4.1. Intervention Phase (Students’ Evaluation)

The pre- and post-intervention questionnaires were designed using selected items from a validated ovulatory menstrual health literacy questionnaire for adolescent girls [26]. These assessed the content taught in the three lessons. Additional items about RMP use and experience were suggested by Modibodi^®, and questions were developed by the research team for the post-intervention questionnaire. There were 54 items in the pre-intervention questionnaire and 58 items post-intervention. Both questionnaires were administered online using Qualtrics^® and took approximately 20 min to complete.

Participant names and schools were used to match responses in the pre- and post-intervention questionnaires and to capture participant numbers across the schools. The lead author de-identified the data by replacing each participant’s name with a pseudonym and allocating a code to each school. This ensured participants’ anonymity when the RMPs were ordered and distributed. The master document with names and codes was filed in a separate folder and stored on a secure research drive accessible only to the research team.

The pre-intervention questionnaire asked participants (n = 96) to provide their dates of birth and first bleed to calculate their age and gynecological age (number of years since menarche) [27]. They then answered the ovulatory menstrual health literacy items (n = 39). The final question asked for participants’ sizes so that the correct fit of RMP was ordered from Modibodi^®.

The post-intervention questionnaire invited three open-ended responses, which replaced the pre-intervention items on sizing. Participants (n = 63) were asked to comment on their experience of the RMP regarding their mindset around menstruation, on the impact of the RMP on managing their bleeds, and on what was learnt from the My Vital Cycles^® lessons.

Ovulatory menstrual health literacy was measured across the domains of functional, interactive, and critical health literacy [11,16]. Responses were captured using 5-point Likert scales (strongly agree to strongly disagree), multiple choices with one correct answer, a corresponding number to an answer, and multiple items’ selection from a list.

Functional health literacy was measured using 12 items in the questionnaire that required participants to identify parts of the female reproductive tract from a diagram, define cycle events, and recognize indicators of healthy cycles. Interactive health literacy was measured using 14 items on sources of ovulatory menstrual health information, attitudes towards the cycle, and cycle experiences. Critical health literacy was measured using 17 items about healthy goal-setting practices and problem-solving. This section included three case studies that assessed the participants’ ability to recognize cycle patterns in determining ‘Day 1’, ‘Ovulation occurrence’, and ‘Day of likely ovulation’ from example charts.

Responses to the pre-intervention questionnaire were collected at students’ convenience prior to program delivery, while responses to the post-intervention questionnaire were collected during the final session of Just 4U™. If participants did not attend the last session, the school staff sent them a reminder email to complete the questionnaire at their convenience.

2.4.2. Post-Intervention Phase (School Staff Interviews)

Staff interview questions began with a general prompt regarding their impressions or opinions of the Just 4U™ program. This discussion was followed with targeted questions on its future utility and implementation, such as fitting into the curriculum, staff confidence in teaching, the program’s strengths and weaknesses, and enablers or barriers to uptake. Interviews were audio recorded on the iOS Voice Memos application and were transcribed using the secure Otter.ai software (Version 3.64.0-241125).

2.5. Data Analysis

2.5.1. Intervention Phase (Students’ Evaluation)

Variables such as age and gynecological age were assessed for normality using a histogram, normal Q–Q plot, and kurtosis coefficients. As these continuous variables were normally distributed, means and standard deviations were used to describe them.

Quantitative data from pre- and post-intervention responses were categorized as either correct or incorrect and agree (strongly agree/agree) or disagree (neither agree nor disagree/disagree/strongly disagree). The associations between program participation (pre- and post-intervention), cycle concerns, and ovulatory menstrual health literacy (correct/incorrect answer for each item) were assessed using Chi-square analyses or Fisher’s exact test where appropriate, with significance set at <0.05. Jamovi (Version 2.3.26) software was used for quantitative statistical analyses.

Qualitative data from the open-ended RMP questions was interpreted using a deductive thematic analysis following Braun and Clarke’s 6-step method [28]. Prior to analysis, participants’ names were substituted with an alias to de-identify them. Their responses were marked by alias, session delivery, and age. Responses for each question were transferred from Excel to Word. Data were familiarized by reading responses to each question. Themes and sub-themes that emerged from quotes were named. Quotes that contained multiple themes were added to all relevant themes. Results were then tabulated and quantified by the number of quotes within a sub-theme to show how frequently it was mentioned. Quotes were provided to exemplify the themes.

2.5.2. Post-Intervention Phase (School Staff Interviews)

Thematic analysis was conducted following Braun and Clarke’s 6-step method [28]. Transcripts were reviewed alongside the recording to ensure they were verbatim and accurate to maintain dependability and determine credibility [29]. The files were uploaded onto the NVivo software (Version 14.23.0). Data were familiarized through thorough reading, and initial codes were developed. To maintain confirmability the data analysis process, including theme formulation and refinement was cross-checked with the research team [29]. The codebook was exported to Excel, and codes were grouped as similar themes emerged. Initial themes were then analyzed within the broader themes of “Utility” and “Implementation”. Sub-themes were given more descriptive names. Finally, quotes from the initial codes were selected to illustrate these sub-themes.

3. Results

3.1. Participant Characteristics

3.1.1. Schools

Fourteen independent co-educational schools from metropolitan and regional areas in Western Australia were invited to participate. School principals (n = 5) provided informed written consent for the trial to proceed in their school. The trials were delivered in each school during 2022. School characteristics are reported in

Table 1. Characteristics of participating schools.

School	A	B	C	D	E
ICSEA §	900–1000	1000	1000–1100	1000–1100	1000–1100
Setting	CARE †, Independent, Co-educational	Independent, Co-educational	Independent, Co-educational	Independent, Co-educational	Independent, Co-educational
Region	Metro	Regional	Metro	Metro	Metro
Participants (n)	Pre: 12 Post: 7	Pre: 10 Post: 10	Pre: 25 Post: 18	Pre: 14 Post: 11	Pre: 35 Post: 17
Trial dates (2022)	Feb-Apr	Apr-Jun	Jun-Aug	Jul-Nov	Jun-Sep
Session Delivery	Classroom	Classroom	Classroom	Classroom	Lunchtime

^§ Index of Community Socio-Educational Advantage (ICSEA). Mean 1000, standard deviation 100, range 500–1300 [24]. Actual score blinded. ^† Curriculum and Rearrangement in Education (CARE). School accommodates students who are unable or have difficulty in accessing mainstream schooling [30].

.

3.1.2. Student Participants

Of the 96 participants who completed the pre-intervention questionnaire, 63 completed the post-intervention questionnaire. Overall, the retention rate was 65.6%. However, the lunchtime group had a retention rate of 48.6%. The mean age of participants was 15.5 years, and they had been menstruant for an average of 3.1 years. Pain and poor mood were their most frequently reported cycle concerns at 68.9% and 61.5%, respectively (

Table 2. Characteristics of student participants.

Participant Characteristics	Pre-Intervention (n = 96)	Post-Intervention (n = 63)
Retention rate | n (%)
Lunchtime	35 (100.0)	17 (48.6)
Classroom	61 (100.0)	46 (75.4)
Total	96 (100.0)	63 (65.6)
Mean age | years (n)
Lunchtime	16.3 (35)	16.5 (17)
Classroom	15.0 (61)	15.3 (46)
Total	15.5 (96)	15.7 (63)
Mean gynecological age § | years (n)
Lunchtime	3.6 (35)	3.7 (17)
Classroom	2.8 (61)	3.4 (46)
Total	3.1 (96)	3.4 (63)
Cycle concerns | n (%)
Pain with bleed	67 (68.9)	42 (68.9)
Poor mood	59 (61.5)	38 (62.3)
Nausea	39 (40.6)	23 (37.7)
Irregular cycles	35 (36.5)	14 (23.0)
Pain without bleed	23 (24.0)	14 (23.0)
Heaviness of bleed	24 (25.0)	12 (19.7)
Length of bleed	21 (21.9)	11 (18.0)
None	4 (4.2)	10 (16.4) *

^§ Gynecological age is defined as the number of years since menarche [27]. * p < 0.01.

). Concerns about irregular cycles decreased by 13.5%, although this was not statistically significant. The reporting of no cycle concerns increased from 4.2% to 16.4% post-intervention and was statistically significant (p = 0.009).

3.2. Intervention Phase (Students’ Evaluation)

3.2.1. Participants’ Ovulatory Menstrual Health Literacy (My Vital Cycles^®)

Functional health literacy was measured using questions that required participants to identify parts of the female reproductive anatomy from a diagram, define key cycle events and female fertility, and recognize indicators of healthy cycles. Overall, participants’ knowledge of anatomy increased post-intervention. The correct identification of the vulva (Item 1.2) and vagina (Item 1.5) saw the greatest improvement, increasing by 20.3% and 23.1%, respectively (p < 0.05). Participants’ knowledge of key cycle events (Items 1.6–8) and female fertility (Items 1.9–12) also improved (p < 0.05). Although there were significant increases in correctly defining ‘Ovulation Occurrence’ (Item 1.8) and ‘Meaning of Cervical Fluid’ (Item 1.12), less than 50% answered correctly post-intervention. Findings are reported in

Table 3. Participants’ functional ovulatory menstrual health literacy.

Questionnaire Item	Pre-Intervention n (%) Lunchtime (n = 35) Classroom (n = 61) Total (n = 96)	Post-Intervention n (%) Lunchtime (n = 17) Classroom (n = 46) Total (n = 64)	p-Value
1.1. Identify Cervix	27 (77.1)	11 (68.8) †	0.205
	35 (57.4)	35 (76.1) *
	62 (64.6)	46 (74.2) †
1.2. Identify Vulva	20 (57.1)	9 (56.3) †	0.012
	24 (39.3)	32 (69.6) *
	44 (45.8)	41 (66.1) †*
1.3. Identify Ovary	31 (88.6)	13 (81.3) †	0.908
	52 (85.2)	41 (89.1)
	83 (86.5)	54 (87.1) †
1.4. Identify Uterus	31 (88.6)	13 (81.3) †	0.797
	48 (78.7)	39 (84.8)
	79 (82.3)	54 (83.9) †
1.5. Identify Vagina	18 (51.4)	11 (68.8) †	0.004
	28 (45.9)	33 (71.7) *
	46 (47.9)	44 (71.0) †*
1.6. Define ‘Day 1’	13 (37.1)	10 (66.7) ‡	0.014
	34 (55.7)	32 (69.6)
	47 (49.0)	42 (68.9) ‡*
1.7. Healthy length of menses	11 (31.4)	8 (53.3) ‡	<0.001
	20 (32.8)	41 (89.1) **
	31 (32.3)	49 (80.3) ‡**
1.8. Define Ovulation Occurrence	4 (11.4)	4 (26.7) ‡	0.002
	4 (6.6)	12 (26.1) *
	8 (8.3)	16 (26.2) ‡*
1.9. Ovum Survival	5 (14.3)	8 (53.3) ‡	<0.001
	5 (8.2)	35 (76.1) **
	10 (10.4)	43 (70.5) ‡**
1.10. Ovum Age	16 (45.7)	11 (73.3) ‡	<0.001
	13 (21.3)	36 (78.3) **
	29 (30.2)	47 (77.0) ‡**
1.11. Age of Difficulty Achieving Pregnancy	17 (48.6)	12 (80.0) ‡	<0.001
	10 (16.4)	29 (63.0) **
	27 (28.1)	41 (67.2) ‡**
1.12. Meaning of Cervical Fluid	6 (17.1)	9 (60.0) ‡*	<0.001
	11 (18.0)	21 (45.7) *
	17 (17.7)	30 (49.2) ‡**

* p < 0.05, ** p < 0.001, ^† 1 missing, ^‡ 2 missing.

.

Most participants expressed positive attitudes and beliefs regarding the cycle pre-intervention. Furthermore, the belief that pain and poor mood are normal (Items 2.6–7) decreased by 24.0% and 22.3%, respectively (p < 0.001). Findings are reported in

Table 4. Participant’s interactive ovulatory menstrual health literacy.

Questionnaire Item	Pre-Intervention n (%) Lunchtime (n = 35) Classroom (n = 61) Total (n = 96)	Post-Intervention n (%) Lunchtime (n = 17) Classroom (n = 46) Total (n = 64)	p-Value
2.1. Cycle knowledge helps self-understanding	31 (88.6)	13 (76.5)	0.463
	47 (77.0)	41 (89.1)
	78 (81.3)	54 (85.7)
2.2. Cycle knowledge helps determine good health	32 (91.4)	17 (100.0)	0.266
	49 (80.3)	40 (87.0)
	81 (84.4)	57 (90.5)
2.3. Cycle knowledge helps symptom management	34 (97.1)	17 (100.0)	0.651
	49 (80.3)	39 (84.8)
	83 (86.5)	56 (88.9)
2.4. Cycle knowledge helps to confidently manage health	31 (88.6)	15 (88.2)	0.531
	46 (75.4)	38 (82.6)
	77 (80.2)	53 (84.1)
2.5. Menarche is a milestone	25 (71.4)	14 (82.4)	0.382
	34 (55.7)	29 (63.0)
	59 (61.5)	43 (68.3)
2.6. Belief that period Pain is normal	30 (85.7)	13 (76.5)	<0.001
	54 (88.5)	27 (58.7) **
	84 (87.5)	40 (63.5) **
2.7. Belief that Low Mood is normal	33 (93.4)	14 (82.4)	<0.001
	54 (88.5)	29 (63.0) *
	87 (90.6)	43 (68.3) **

* p < 0.05, ** p < 0.001.

.

Overall, participants’ menstrual health practices did not change post-intervention. There was no statistically significant impact on using the cycle for healthy goal setting (Items 3.7–9), and overall, less than 40% of participants reported doing this. However, the areas of greatest improvement were in using their cycle for self-care (Item 3.6, 63.0%) and having awareness of evidence-based remedies to alleviate poor menstrual symptoms (Item 3.4, 82.0%).

When it came to problem-solving, their abilities markedly increased. These findings are reported in

Table 5. Participants’ critical ovulatory menstrual health literacy.

Questionnaire Item	Pre-Intervention n (%) Lunchtime (n = 35) Classroom (n = 61) Total (n = 96)	Post-Intervention n (%) Lunchtime (n = 17) Classroom (n = 46) Total (n = 64)	p-Value
3.1. Know Start of personal cycle	7 (20.0)	1 (6.7)	0.404
	20 (32.8)	20 (43.5)
	27 (28.1)	21 (34.4)
3.2. Know personal Likely Ovulation	3 (8.6)	3 (20.0)	0.013
	11 (18.0)	15 (34.8) *
	14 (14.6)	18 (31.1) *
3.3. Predict next period	17 (48.6)	7 (46.7)	0.073
	32 (52.5)	33 (71.7) *
	49 (51.0)	40 (65.6)
3.4. Aware of remedies	23 (65.7)	13 (86.7)	0.049
	42 (68.9)	37 (80.4)
	65 (67.7)	50 (82.0) *
3.5. Confident talking to health care professional	18 (51.4)	9 (60.0)	0.733
	36 (59.0)	27 (58.7)
	54 (56.3)	36 (59.0)
3.6. Use cycle for self-care	7 (20.0)	10 (66.7) *	0.004
	32 (52.5)	29 (63.0)
	39 (40.6)	39 (63.9) *
3.7. Use cycle for healthy eating	12 (34.3)	1 (6.7)	0.214
	29 (47.5)	19 (58.7)
	41 (42.7)	20 (32.8)
3.8. Use cycle for healthy activity	8 (22.9)	4 (26.7)	0.367
	23 (37.7)	20 (43.5)
	31 (32.3)	24 (39.3)
3.9. Use cycle for healthy sleep	8 (22.9)	3 (20.0)	0.899
	26 (42.6)	18 (39.1)
	34 (35.4)	21 (34.4)
3.10.1. Case 1: Day 1	20 (57.1)	12 (80.0) ‡	0.080
	43 (70.5)	36 (78.3)
	63 (65.6)	48 (78.7) ‡
3.10.2. Case 1: Ovulation Occurrence	20 (57.1)	10 (66.7) ‡	0.009
	36 (59.0)	38 (82.6) *
	56 (58.3)	48 (78.7) * ‡
3.10.3. Case 1: Day of Likely Ovulation §	1/20 (5.0)	4/10 (40.0) ‡*	<0.001
	0/36 (0.0)	19/38 (50.0) **
	1/56 (1.8)	23/48 (47.9) ‡**
3.11.1. Case 2: Day 1	21 (60.0)	11 (73.3) ‡	0.090
	42 (68.9)	36 (80.0)
	63 (65.6)	47 (78.3) ‡
3.11.2. Case 2: Ovulation Occurrence	19 (54.3)	10 (66.7) ‡	0.002
	27 (44.3)	34 (75.6) *
	46 (47.9)	44 (73.3) ‡*
3.11.3. Case 2: Day of Likely Ovulation §	0/19 (0.0)	3/10 (30.0) ‡*	<0.001
	0/27 (0.0)	14/34 (41.2) **
	0/46 (0.0)	17/44 (38.6) ‡**
3.12.1. Case 3: Day 1	4 (11.4)	3 (20.0) ‡	<0.001
	7 (11.5)	20 (44.4) **
	11 (11.5)	23 (38.3) ‡**
3.12.2. Case 3: Ovulation Occurrence	7 (20.0)	11 (73.3) ‡**	<0.001
	14 (23.0)	26 (57.8) **
	21 (21.9)	37 (61.7) ‡**

* p < 0.05, ** p < 0.001, ^‡ 2 missing; ^§ Items 3.10.3 and 3.11.3 have been reported as percentages of Items 3.10.2 and 3.11.2, respectively. This follows the logic from the questionnaire; of those who answered ’Ovulation Occurrence’ correctly, these identified ’Day of Likely Ovulation’ correctly.

. When presented with example charts, ‘Cases 1–3’ (Items 3.10–12), participants were invited to identify ‘Day 1,’ whether ovulation occurred (‘Ovulation Occurrence’) and, if so, the ‘Day of Likely Ovulation’.

3.2.2. Participants’ Perspectives on the Reusable Menstrual Product (Modibodi^®)

Participants (n = 59) answered open-ended questions on the impact of the RMPs on health or mindset around bleeds, cycle management, and anything else learnt from the Just 4U™ program. The frequency of theme recurrence has been reported since some participant responses covered multiple sub-themes. Recurrent themes are reported in

Table 6. Participants’ perspectives on RMPs and Just 4U™.

Question 1: Impact of RMP on health or mindset around bleed
Themes	Sub-themes	Frequency (n)	Illustrative Quote
Positive impact	No leaking	18	“I realize that there are ways to relieve the discomfort on my period. Even though the pants didn’t help with what was going on internally, they made me more comfortable”.—Isabella (School C, 14 years) “Using the period pant made me feel a lot more comfortable … sometimes I even forgot that I had my period because I just didn’t notice it and wasn’t always conscious about it leaking etc. It has made me think that periods aren’t so bad anymore…”—Eliana (School E, 17 years) “I feel better as I am not damaging the environment and am being environmentally conscious”.—Elizabeth (School B, 15 years)
	Comfort	10
	Confident	11
	Easy to use	4
	Easy to be active	4
	Wear at night	3
	Sustainable	3
	Prefer to disposable	2
	Positive feelings towards periods	2
No difference	No difference	14	“…my health is the same and my mindset has been improved with the sessions, not with the pants”.—Everly (School D, 14 years)
	Sessions improved mindset	2
Have concerns	Smell or hygiene	3	“I do tend to use them still with a pad, since I don’t trust the hygiene as much. However, I do feel more secure and positive that my chances of leaks are lower since I have the backup to support a wonky pad..”.—Zoe (School E, 16 years)
	Leaking	2
	Difficulty using	1
Question 2: Impact of RMP on cycle management
Themes	Sub-themes	Frequency (n)	Quote
Positive impact	Prepared for period	10	“The reusable pants have changed my life because it has made it so much easier to manage school and sports. I don’t have to worry about any leakage”.—Penelope (School C, 14 years) “It has changed because now I’m always ready when my period starts”.—Camila (School B, 14 years)
	Minimize waste	6
	More aware of cycle	5
	Comfort	5
	Easier than disposable items	4
	Good to sleep in	4
	Not afraid of leaking	2
	More active	1
No difference	No change or unsure	21	“I wear the reusable pad as insurance, with the disposable on top. So it hasn’t really changed”.—Everly (School D, 14 years)
	Extra protection	3
Question 3: Anything else learnt from the Just 4U™ program
Themes	Sub-themes	Frequency (n)	Quote
Learnt something new	What is healthy	14	“My Vital Cycles® helped me learn how to track and how long/heavy my period should be”.—Harper (School B, 14 years)
	Ovulation	13
	Own body	6
	Tracking cycle	5
	Benefits of RMP	4
More confident	Talk/ask questions	6	“That it is okay for girls to talk to people about their cycle/period and it should be a normal thing”.—Penelope (School C, 14)
	About having period	1
Enjoyed Just 4U™	Liked RMP	6	“The pants have allowed me to open my eyes to more useful innovations and to trust them, or use them. Although I haven’t fully trusted them I’m looking for more innovative, efficient innovations to help open my perspectives further”.—Zoe (School E, 16 years)
	Overall	6

.

Many participants found the RMPs had a positive impact on their mindsets. The key reasons for this were that they were leak-proof, comfortable, easy to use, and made them feel confident. One participant wrote that the lessons had a greater impact on her mindset than the RMP. Some participants reported no difference in their mindset or health, but a few were concerned about hygiene and leaks.

There were many positive comments towards the RMP, particularly relating to how it helped them manage their bleeds. Participants reported several ways RMPs improved their cycle management. The most frequent reasons were that they were more prepared for their period; RMPs helped them minimize waste; RMPs helped them become more aware of their cycle health; and in general, the RMPs were comfortable. A few reported feeling less stressed and not even ‘conscious’ of their period when using RMPs. While many positive impacts from RMPs were mentioned, ‘no change’ in cycle management was frequently reported (n = 21), and some preferred not to use RMPs (n = 3).

The most common comment on the Just 4U™ program was learning something new. Participants most frequently reported learning more about ovulatory menstrual health, especially regarding bleeds, pain, and ovulation. In addition, feeling more confident to talk with others and manage their cycles was frequently reported.

3.3. Post-Intervention Phase (School Staff Interviews)

Staff (n = 14) provided written consent to assist in implementing the trial, six of whom consented to an interview after program delivery from four schools. Those interviewed included two health and physical education (HPE) teachers, one science teacher, one drama teacher, one counselor, and one chaplain. No staff from the CARE school were interviewed due to challenges with follow-up. Three broad themes regarding the utility and implementation of Just 4U™ emerged: (1) Just 4U™ was relevant and empowering for Grade 9–12 girls; (2) Improvements to Just 4U™; and (3) Ideal and effective delivery of Just 4U™.

3.3.1. Theme 1: Just 4U™ Was Relevant and Empowering for Grade 9–12 Girls

Staff recognized menstrual disturbances impacted their students’ schooling and often mentioned the support services provided by the school, such as the nurse for pain relief and the psychologist, counselor, or chaplain to talk through and advise on difficult experiences. Most commented on the importance of the whole school being equipped to support students and believed the program benefited students as it taught them how to understand their own cycle.

A few staff members commented on the importance of raising awareness about sustainability and hygiene practices. They believed the inclusion of RMPs facilitated the connection to students’ cycles.

“I think that [the Modibodi^® RMP] were a really good incentive and like a nice physical way for students to connect with themselves and their cycles...”

—Drama Teacher, School E

Most staff perceived the concepts taught in the program’s lessons as initially quite daunting. However, as the sessions progressed, they saw participants become engaged and more open. One HPE teacher reported that the lessons helped to break the taboo both in and outside class.

“…They’re very open to tell the boys or to tell the girls that weren’t in the class… They feel quite proud of having this extra knowledge… I thoroughly enjoyed watching the girls teaching the rest of the class what they had learned”.

—HPE Teacher, School B

They believed discussions around female fertility were appropriate to their life stage because they focused on their own cycle experiences.

“…I’m nearly into 40 years of teaching; This was never addressed. It was just, “Here are the facts”, ‘the birds and the bees’ type of story, and it was all about procreating. Now, you’re getting into more and more detail [about the cycle], and also making people aware of how the body is working”.

—Counsellor, School C

3.3.2. Theme 2: Improvements to Just 4U™

The participants who were teachers recommended more frequent sessions to reinforce content, break up the complex concepts, and build on existing knowledge. One teacher suggested that delivering the program across each grade of high school could be useful.

The staff from the lunchtime sessions suggested that a parent session would be a worthwhile inclusion. Introducing parents to what was being taught may facilitate conversations at home and help them better understand and support their daughters.

“Even doing like a parent session… how to support your daughter through their menstrual cycle and ways to navigate any challenges that may arise”.

—Chaplain, School E

3.3.3. Theme 3: Ideal and Effective Delivery of Just 4U™

Staff perceived that the co-educational setting had unique challenges for menstrual health education. They suggested that an understanding of the cycle could help boys understand the experience of menstruation and that this would be important for relationships with women in their lives. However, they recognized that girls may be uncomfortable discussing personal cycle management with boys in class.

Moreover, staff discussed advantages and challenges for male teachers. The teacher and girls may feel awkward discussing the cycle, but conversations with male teachers could help to break the stigma around the cycle by “normalizing those conversations” (Drama Teacher, School E).

While they believed that the cycle was important to be taught in HPE, they commented on the limited capacity of the curriculum. Another observed that HPE teachers’ “passions often lie in sport” and they may be “afraid of saying the wrong thing” in health (Drama Teacher, School E). To combat these challenges, they suggested the program had scope to be implemented in other courses.

“I think because it’s so cross curriculum, we can already bring a lot of this stuff in as part of what we already have to do… I think definitely use it in science”.

—Science Teacher, School D

The information from the sessions interested the staff, and a few teachers commented that they had learnt new concepts about the cycle. They felt professional development would ensure an accurate and consistent delivery of the content from My Vital Cycles^®.

“…that would be your professional learning… And I would do it for all staff, not just females… Maybe you just do the Health and Science staff, and let it start from there and then disseminate”.

—Counsellor, School C

4. Discussion

My Vital Cycles^® and Modibodi^® collaborated in the Just 4U™ program to address period poverty by providing menstrual health education and increasing access to RMPs. This study evaluated if Just 4U™ was effective at improving students’ ovulatory menstrual health literacy in co-educational schools. It also explored students’ perspectives and experience of RMPs alongside ovulatory menstrual health literacy lessons, and it sought to understand school staff’s perspectives.

It was found that participants’ ovulatory menstrual health literacy had improved after attending the three lessons of Just 4U™, particularly in their knowledge of female anatomy and understanding key cycle events. Participants generally had positive experiences using RMPs, noting that they were comfortable and helped them manage their bleeds better.

Staff believed the program was beneficial to the participants. They recognized the co-educational setting presented challenges. They thought that the program had scope to be implemented within different learning areas and that training staff would be beneficial.

4.1. Period Poverty: Menstrual Health Education

While pain and low mood are common menstrual experiences for adolescents, these experiences are often perceived as ‘normal,’ and adolescents may not know how to improve them [6]. Findings from this study indicate that Just 4U™ challenged the normalization of pain and low mood and raised awareness of evidence-based remedies to improve poor symptoms. Just 4U™ took a positive approach by teaching self-advocacy and agency over personal health.

Teaching anatomy is an important part of menstrual health education [8]. Often, the vulva and vagina are poorly identified by young women [31,32,33]. The greatest improvement in anatomical knowledge after Just 4U™ was in the correct identification of these parts. Since the vulva is poorly understood, it was an important inclusion in the program. Knowledge of the vulva is important for hygiene practices [34], and its sensory abilities give women awareness of their cycle [35].

The lessons in Just 4U™ instructed students on how the cycle worked. Their ability to identify the occurrence of key cycle events improved. However, these results were lower than those in the 2021 trial of My Vital Cycles^® [16]. Knowledge is retained when information is frequently reinforced [36]. The lower result could be attributed to the Just 4U™ program having only three lessons rather than the six lessons implemented in the My Vital Cycles^® trial [16]. Future implementation of Just 4U™ could be strengthened by increasing the number of lessons included.

Furthermore, staff thought Just 4U™ was beneficial as it addressed fertility in a life-stage-appropriate way. Understanding fertility has been addressed through the lens of pregnancy avoidance in interventions [37]. However, Just 4U™ focused on understanding the cycle as a reflection of good health first and foremost [15], rather than as a means of pregnancy avoidance or achievement.

4.2. Period Poverty: Including Reusable Menstrual Products in Education

It has been reported that young women would like to learn more about RMPs [20,38]. Trialing RMPs alongside ovulatory menstrual health education was one way that Just 4U™ explored this. Findings from this study suggest that including RMPs benefited participants’ education by improving their mindset towards menstruation and helping them be prepared for their bleeds. Furthermore, staff saw RMPs as a tangible way for participants to connect with their cycles. Protection from leakage and comfort were important aspects of RMPs to participants, which previous research in HICs has highlighted [20,21]. The impact of education with menstrual care products has been beneficial to young women in low-middle income countries [39]. However, trials of RMPs are not widespread in HICs [21]. To the best of the researchers’ knowledge, this study is the first to report the experience of RMPs within an ovulatory menstrual health literacy program in an HIC.

Adolescent girls can experience irregular cycles during their early years postmenarche [40], which makes the next bleed difficult to predict. These findings suggest that RMPs helped participants feel more prepared for their bleeds, and they enjoyed the comfortable and user-friendly aspects of an RMP. A review found that the mental burden of menstruation and the need to be prepared for periods can cause stress for women in HICs [41]. Findings from this study suggest that RMPs may relieve the cognitive load surrounding the management of bleeds.

While many participants reported improvement in their cycle management, almost half reported no change. One explanation is that RMP uptake has been reported to be higher among women aged 26–35 years in HICs [42]. Alternatively, since participants had a mean gynecological age of 3.1 years, they may already have been confident in managing their bleeds. Future research could consider the impact of RMPs in HICs on menstrual experiences and cycle management of adolescents who are premenarcheal or just starting their menstrual journey.

4.3. Implementing Just 4U™

Staff identified several challenges of menstrual education in a co-educational school setting. A few cautioned that there may be a level of immaturity around the topic amongst male students. However, they recognized the benefit of learning about the cycle for all students. Gundi et al. found that male students aged 13–19 years (n = 21) in urban India were curious about menstruation [43]. Findings from Just 4U™ suggest that the lessons about cycle science could be implemented in science classes for all students, while lessons on personal cycle management could be implemented in health class for those who currently or will menstruate.

Similar to previous studies, this study discovered the need for teacher training in ovulatory menstrual health education [12,44,45,46]. Notably, Brown et al. found that male teachers are often uncomfortable when teaching about menstruation [44]. While this study did not interview male staff, it would be essential to consider their perspectives when designing training for ovulatory menstrual health education.

Finally, staff highlighted that parent involvement in ovulatory menstrual health education would be beneficial, as their role in supporting the health of their children is important [12]. It was suggested that a parent-student session is added to Just 4U™. This could be achieved by adopting the complete My Vital Cycles^® program, which includes a parent-student session.

4.4. Strengths and Limitations

A strength of this study was that it contributed to the literature on using RMPs combined with a program to deliver ovulatory menstrual health education in an HIC setting. Another strength is that this study demonstrated that just three lessons from My Vital Cycles^® enabled adolescent ovulatory menstrual health literacy to improve.

The quality of these lessons meant that complex concepts were accessible and understood by students from schools that were of average to below-average ICSEA scores. Additionally, the participation of a school from a regional area suggests the uptake of the program can be expanded beyond metropolitan areas.

Finally, interviewing staff as part of the mixed methods evaluation was a strength of the study. Using mixed methods and engaging additional stakeholders for the same phenomenon adds validity to the study design [47]. These additional data sources gave depth to the evaluation of the program and explored potential ways for future implementation. Female staff volunteered to be involved in the study. Future trials could aim to engage male staff.

A limitation of the study design was that it had one arm; hence the impact of the program on the students’ ovulatory menstrual health literacy could not be compared to a control group. A future study could randomly assign control and intervention groups.

Self-selection bias may have results in the recruitment of participants who have been interested or knowledgeable in menstrual health. This may explain the generally positive attitudes towards the cycle pre- and post-intervention and the positive reception of RMPs. Self-selection bias may also explain the lower retention rate for the lunchtime setting. Students who volunteered their time could be more likely to be involved in other extracurricular lunchtime activities. Although there was minimal impact on the results, a robust comparison could not be made between these settings.

The study was not designed for male or premenarcheal students because of the RMP trial. The feedback from staff indicates the need to further explore the implementation of ovulatory menstrual health education in a co-educational context within the classroom for all genders and life stages.

The RMPs trialed were period underwear. This enabled insight only into experiences specific to the use of these. Future research could explore menstrual cups and reusable pads.

While our research addressed the educational aspects of period poverty, the association between socioeconomic status (SES) and barriers to RMP access was not explored. As RMPs were positively received, there is scope for further research to understand barriers and enablers to their uptake in low SES or rural contexts within HICs.

5. Conclusions

This study aimed to evaluate the impact of the Just 4U™ program on period poverty in co-educational schools of average to below-average socio-educational advantage. After the program, the ovulatory menstrual health literacy of Grade 9–12 postmenarcheal adolescents improved, and RMPs provided by Modibodi^® were positively received. Adopting the complete My Vital Cycles^® program would reinforce ovulatory menstrual health learnings and allow the inclusion of parents. Training school staff to deliver the program is recommended for future trials.