Recent studies report that Haitian women are concerned about unmet women's health issues. The Days for Girls (DfG) International program features women's health education and personal hygiene kits to ensure women understand the process of menstruation and use sanitary hygiene practices. The aims of this study were to identify the perceived benefits and challenges to using the DfG International program kits for high school and college women in Haiti and to identify ways to adapt the current DfG program for Haitian culture. A post-use survey design was used to study the perceptions of young women in Leogane, Haiti. Forty-four women (89.9%) from the Episcopal University of Haiti and fortyeight women (86%) from Saint Croix High School used the DfG kits for two-months and completed the post-use survey. Although neither group ranked lack of feminine hygiene products as the most critical reason for school absences, both groups agreed that there is a need for feminine hygiene programs in Haiti and the DfG kits were easy to use and clean. Both groups recommended changes in the design of the DfG hygiene products to make the shields and liners more comfortable and suggested the kits would be more widely accepted if white in color. The DfG program could provide a cost-effective feminine hygiene program for Haiti and future studies should focus on distribution of the kits in the more rural areas.

Keywords: Women's health, Feminine hygiene, Menstruation

This research contributes to our understanding of women's health issues in lowresource countries. The Days for Girls International program could address important reproductive health issues in Haiti and provide cost-effective, reusable personal hygiene supplies, which may decrease waste accumulated from traditional feminine hygiene products (i.e. tampons, Kotex, panty liners, pads).

Healthcare practitioners, including occupational therapists and physical therapists, are well-suited to address menstrual education and women's health issues due to a strong foundation in the biological, physical, social, and behavioral sciences which support an understanding of occupations across the lifespan and knowledge of the daily roles and habits of individuals in different contexts. Occupational and physical therapy practitioners are trained to provide care related to women's health, whether it involves pelvic floor disorders, post-partum incontinence or feminine hygiene education and management. The rapist are among the many healthcare providers who are responsible for ensuring that young women in low resource countries receive proper and preventative education on reproductive health. Young women in low-resource countries are less likely to receive formal education about the female anatomy, menstruation, and prevention of potential medical issues which can impact reproductive health. It common for women to learn misinformation about feminine hygiene and reproductive health through local cultural beliefs and taboos which can greatly impact health behaviors.1-3 In addition, when young women in low resource countries begin to menstruate, they may have limited access to sanitary napkins and instead use unsanitary products such as old cloths, tissue paper, cotton or wool pieces, leaves, or even sit on cardboard pieces during their monthly cycle [1-5].
When women do not have access to sanitary napkins, they are at greater risk for infection and are less likely to attend school during their monthly menstrual cycle. Recent studies have determined the influence of menstruation and access to sanitary products on schoolgirl absenteeism[1-4].Poverty affects both men's and women's health, but that it yields a higher burden on women and girls health due to cultural practices related to women's health.1,4-6 Gender equity in education has long been heralded as a cornerstone for social and economic development and if girls are routinely missing school, this reduces their ability to complete their education and decreases their capacity to contribute to their family and communities[1-3,5].

Occupational and physical therapy practitioners working in low resource countries, such as Haiti, are positioned to offer innovative solutions to women's feminine hygiene needs, promote health equity, and help develop healthy patterns of occupation that meet women's health needs. The 2010 earthquake in Haiti has been reported to be one of the most destructive natural disasters of the early 21st century [7].Public health response has focused on disaster relief and management of specific diseases, however recent studies have determined that Haitian women remain to be concerned about unmet basic health needs [7-9].
This includes a lack of access to affordable, sanitary feminine hygiene products. Unfortunately, there are no published studies on the use and disposal of these products in Haiti. Moreover, Haiti has virtually no waste management system, making provision of free disposable feminine hygiene products a poor solution [10-12].

Days for Girls (DfG) International is a 501(c)3 non-profit organization leading the effort for women's health issues in low income countries since 2008, the DfG program has established chapters in over 550 locations across 85 countries reaching over 200,000 women [13]. Program articles can be found in the Stanford Social Innovation Review, Oprah Magazine, the Huffington Post, and National Public Radio and the organization was featured in the 2013 UN Commission on the Status of Women report [14].
The DfG concept is simple: in-country chapters are trained how to produce and distribute menstrual education and reusable personal hygiene kits which consist of cloth pads with plastic pads that can be washed with little water and can be reused for up to three years. The DfG International program was designed to ensure young women understand the process of menstruation and have solutions for personal feminine hygiene.
In countries that the DfG program has been successfully implemented, the program has been shown to improve girls' attendance in secondary school and reduce the social stigma from unsanitary and unhealthy feminine hygiene habits [2,5,15].

In addition to addressing unmet women's health issues, a DfG program in Haiti could provide cost-effective, reusable personal hygiene supplies, lessening the waste products accumulated from traditional feminine hygiene materials (i.e. tampons, Kotex, panty liners, pads). A DfG program in Haiti has the potential to not only benefit women's health and feminine hygiene practices, but contribute to current efforts to improve waste management and sanitation.
To date, the DfG has not been implemented in Haiti, therefore our research question is: What are the perceptions of women in Haiti who use the DfG feminine hygiene kits? This study examined the use of the DfG International program with two groups of women located in Leogane, Haiti. The study had two aims: 1) To identify the perceived benefits and challenges to using the DfG International program kits for high school and college women in Haiti and 2) to identify ways to adapt the current DfG program for Haitian culture. We predicted that the program would be well-accepted by the majority of women, but would require adaptations to meet the specific needs of Haitian women. In addition, we predicted that there would be a difference in the perceptions of the DfG program between high school and college women after using the feminine hygiene kits based on level of education about female anatomy and menstruation.

A post-survey only design was used to study the perceptions of two cohorts of young Haitian women who used the DfG feminine hygiene kits for two-months. DfG provided specific patterns for each item in the reusable hygiene kit (pads and shields) and specific instructions on how to assemble and sew each item (Figure 1, http://www.daysforgirls.org/). The reusable hygiene kits consist of one drawstring bag to hold all the contents, eight absorbent tri-fold pads, two moisture barrier shields, visual instructions, one-gallon size Ziploc bag (Figure 1).
Haitian seamstresses and seamstresses from the non-profit Helping Haiti Work, who are approved providers of the DfG hygiene kits, provided all the kits for this study.

This study involved two cohorts of Haitian women of differing ages and education levels. Cohort 1 included 49 women from the Episcopal University of Haiti between the ages of 18 and 24 years. Cohort 2 included 56 women from the Saint Croix High School between the ages of 12 and 17 years. This study was approved by the Institutional Review Board at the Medical University of South Carolina and participants enrolled and consented to participate in this study. The participants were informed of the study's risks and benefits, their participation was voluntary, and their identity is not disclosed and any data described in this paper.

All participants were surveyed two-months after using the DfG reusable feminine hygiene kits. The survey included Likert-scale questions (1-strongly disagree, 2-disagree, 3-agree, 4-strongly agree) to assess the young women's perceptions of the reusable personal hygiene kits including need for feminine hygiene in products in Haiti, ease for use, and ease for cleaning the reusable pads and shields [14]. In addition, the survey had specific open-ended questions related to the perceived benefits of the DfG kits, any challenges or barriers, and suggestions for further distribution of the kits in Haiti. For school attendance, we used a participatory ranking exercise and participants ranked, in descending order, reasons for absenteeism (ie. inability to pay school fees, household chores, lack of feminine hygiene supplies).

Perception of Using the DfG Hygiene Kits Forty-four women (89.9%) from the Episcopal University of Haiti (Cohort 1), average age 20.2 years. All participants in this cohort were women enrolled in a baccalaureate degree nursing program. Forty-eight women (86%) from Saint Croix High School (Cohort 2) completed this study, average age 16.9 years. All participants were enrolled in high school level courses. In addition, six of the women from each cohort participated in the focus group interviews conducted in Leogane. The women who participated in the focus groups were a convenience sample of participants who volunteered to be part of a group interview following use of the DfG hygiene kits. Women enrolled in the study who did not use the DfG kits for two months did not complete the post-use survey. Women in both Cohort 1 and Cohort 2 who used the DfG hygiene kits for two-months overwhelming agreed that there is a need for feminine hygiene programs in Haiti and that the DfG program was easy to understand and use. The participants agreed that the DfG reusable products could be cleaned to prevent infections (Table 1). There was strong agreement between the responses to the Likert scale questions from women in Cohort 1 and Cohort 2 and no statistically significant differences were noted (p-values >0.05).

Many of the young women in Cohort 2 placed a stronger emphasis on the educational component of the DfG program and the fact that it helps with prevention of infectious diseases. ""I like the way the kits were given to us and the information about the menstrual cycle", "I like everything in the kits, the colors, the way the kits were distributed, and the information provided to us like the way the you explained the menstrual cycle" and another participant reported, "I like this kit because it helps me protect from diseases." In terms of perceived challenges, the young women from Cohort 2 felt that the products were uncomfortable, although this contradicts perceptions of the women from Cohort 1. One participant from Cohort 2 noted, "The attachments hurt me. They are so hard" and another reported, ""The kit rubs and irritates my thighs". Additionally, the women from Cohort 2 did not prefer the colors of the kits and stated they had problems with the liners and attachments, as the products did not feel well-secured in underwear. One participant stated, "When I wear one pad, it is not enough to absorb, and when I wear two, it is not comfortable".
In terms of future directions, Cohort 2 participants agreed with Cohort 1 and emphasized that the program should continue to be utilized in Haiti to meet Haitian women's menstrual needs and should be expanded upon to offer additional materials and sizes. Participants noted, " Sometimes girls do not have enough money to possess (other) feminine hygiene supplies and this kit is a good way to combat against infections" and "Give more kits, with various size shield for smaller women. Continue with this program in the mountains of Haiti" (Table 2).

We further explored the themes derived from the open-ended questions (benefits of the kits, the challenges of using the kits, and recommendations for the next steps of the DfG program in Haiti) during focus group interviews. We confirmed and noted additional similarities and differences between the perceptions of the DfG program and kit between Cohort 1 and Cohort 2 (Table 3). Young women from both cohorts felt the products were very economical since they could be washed and re-used for threeyears. Cohort 2 (high school students) continued to feel strongly that the educational component was very beneficial in promoting health. Cohort 1 (university students) believed that the program was highly beneficial in helping to protect the environment, but they also noted that the design of the DfG feminine hygiene products needed to be changed. The women in the focus group suggested the liners and shields could be modified to make them more comfortable and attachments should be added to assure they remain secure in the underwear. In addition, many women interviewed in both cohorts felt that the products should be white instead of colorful. White fabric is commonly used for pants and underwear in Haiti and signifies purity or cleanliness. It was also noted that many Haitians use bleach to clean undergarments, such as underwear. While both groups widely felt that the program was beneficial and could be accepted in Haiti, the differences in perceptions between Cohort 1 and Cohort 2 will be helpful in adapting the program for future use by Haitian women of differing ages and education levels.

In addition to the potential public health impact, the young women in our study overwhelmingly perceived the DfG reusable hygiene kits as beneficial, easy to use, and economical. In fact, many participants of our study strongly encouraged the distribution of the DfG kits in more rural areas of Haiti where it is difficult to find and buy feminine hygiene supplies. The results of our study are similar to those found in research on the use of reusable hygiene in low resource countries (ie. Kenya, Tanzania) where women using the products felt a sense of empowerment with the newfound ability to manage monthly menstruation. These studies demonstrated the long-term benefits of reusable hygiene kits could be improvements in girls' attendance in secondary school and reduction of the social stigma from unsanitary and unhealthy feminine hygiene habits [2,5,15,17].
Potential reasons for any differences in the responses between Cohort 1 and Cohort 2 could be due differences in women's health education. The young high school women had minimal, if any, reproductive or sexual education prior to receiving the DfG educational sessions. This was apparent in the focus group interviews from comments made by the young high school students who asked several questions about the process of menstruation, "how many days does a woman ovulate?" and "when I have my period I cannot take a bath because it may cause pain or "when I drink the cold water the blood coagulates". The university students in Cohort 1 were enrolled in a nursing program and have additional knowledge on women's health and menstruation by nature of their school curriculum and number of years of formal education. Additionally, university students may have more experience with menstruation and wearing feminine hygiene products, unlike the high school women who may just have started menstruation, thus creating a difference in expected comfort level with the DfG feminine hygiene shields and liners.
In countries where DfG International has chapters, they found that young women frequently miss four to five days of school each month due to lack of feminine hygiene supplies and these frequent and persistent absences lead to a high rate of females leaving secondary school within two years of starting menstruation[2,13]. In countries that the DfG program has been successfully implemented, the program has been shown to improve girls' attendance in secondary school and reduce the social stigma from unsanitary and unhealthy feminine hygiene habits [1,2,13]. It remains unclear from the results of our survey if a lack of access to feminine hygiene products had an impact on school attendance and absenteeism in Haiti. Although this reason was not ranked number one by our participants, other published studies that investigated women's menstruation and school attendance in low income countries note that the term "sickness" or "illness" covers a wide range of ailments including malaria and gut infections, but is also used as a euphemism for menstrual cramps and menstruation issues more generally [2,3,17]. This could also be true for our participants in Cohort 1 who ranked "illness" as the number one reason for missing school. These studies have also noted that women who live in poverty lack access to adequate feminine hygiene and fear the embarrassment of visible menstrual leaks when away from home. The DfG program and use of absorbent and dependable products has the potential to re-shape the daily experiences of women in low resource countries by reducing any restrictions to stay at home during menstruation. In addition, the participants in Cohort 2 ranked inability to pay school fees as the most frequent reason for missing school. Both groups noted that the DfG program would be an economical and cost-effective way to manage menstruation, which could lead to a substantial cost-savings for young women who are struggling to find funds to attend school.
There may be some cultural barriers to use of the established DfG program women's health and menstrual education program in Haiti. Although most young women in our study liked the colorful design of the pads and shields, several noted that using solid white materials would be more traditional for Haiti as many items are washed using bleach. In addition, some expressed concern about the appearance of going "back to their mother's time" to use of reusable feminine pad versus the more modern disposable pads. Lastly, it was noted from some participants that women in Haiti may have a "phobia" for touching blood products which may be a barrier to cleaning of the reusable pads. Few studies have been published on the feminine hygiene practices of Haitian women related to menstruation. Crossculturally, social norms and beliefs about gynecological health, cleanliness, and female sexual desirability influence women's feminine hygiene health behaviors in low resource countries [18-20]. Broadly, feminine hygiene practices may stem from cultural notions of purity related to blood and corresponding practices of segregating of women during menstruation and the post-partum period to prevent contamination/pollution. Future studies should explore how cultural practices in Haiti may impact the sustainability of using disposable feminine hygiene products.
This study was intended to determine the perceived benefits of the DfG program for women in Haiti and differences in
perception of the product from women and different educational levels. Limitations to this study include the use of only a postsurvey design which does not allow for an analysis of a change in the participant's responses before and after using the DfG hygiene kits. Therefore, it is difficult to determine the impact of the DfG on the feminine hygiene practices of the participants. Future long-term studies should consider a pre- and post-survey design to determine the overall impact of the DfG hygiene program in Haiti, especially in more rural, mountainous areas. In addition, there is a possibility that some of the ideas from our participants and focus group interviews are representative of women in the specific region of Leogane, Haiti. It would be important to consider a wider distribution of the DfG program in more rural areas of Haiti to assure it is culturally relevant and sensitive to the Haitian society.

This paper contributes to our understanding of women's health issues for women in low-income countries. Women's health issues and lack of access to feminine hygiene products could present as barriers to participation in life activities. Future studies on the DfG program in Haiti should focus on expanding the distribution of the DfG kits to include more rural regions (i.e. the mountainous regions), consider design adaptations to increase comfort, and determine mechanisms for marketing the feminine hygiene kits in Haiti.

The Authors declare that there is no conflict of interest.

Funding Statement and Acknowledgement

The Medical University of South Carolina Center for Global Health Faculty Pilot Grant Projects

1. Kuhlmann AS., Henry K , Wall LL. Menstrual Hygiene Management in Resource-Poor Countries. Obstet Gynecol Surv.2017;72(6):356-376.
2. Jewitt S, Ryley H. It's a girl thing: Menstruation, school attendance, spatial mobility and wider gender inequalities in Kenya. Geoforum.2014;56:137-147.
3. Laserson KF, Mohammed A, Phillips-Howard PA. 'We Keep It Secret So No One Should Know' - a qualitative study to explore young school girls' attitudes and experiences with menstruation in Rural Western Kenya. PLoS ONE. 2013;8 (11):1-11.
4. Logie CH, Daniel C. 'My body is mine': Qualitatively exploring agency among internally displaced women participants in a small-group intervention in Leogane, Haiti. Glob Public Health. 2016;11(1-2): 122-134.
5. Malusu LN, Zani, AP. An evaluation of the perception of secondary school students towards menstruation in Kenya. African Journal of Educational Technology.2014;4(1):83-96.
6. Mason L, Nyothach E, Alexander, K, et al. 'We keep it secret so no one should know'--a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural western Kenya. PLoS One. 2013; 8(11):e79132.
7. Behrman JA, Weitzman A. Effects of the 2010 Haiti earthquake on women's reproductive health. Stud Fam Plann. 2016;47(1):3-17.
8. World Health Organization Statistics: Haiti 2017.
9. Urrutia P, Delson A, Merisier B et al. Unmet health needs identified by Haitian women as priorities for attention: a qualitative study. Reprod Health Matters.2012;20(39):93-103.
10. Cianelli R., Mitchell E, Albuja L, et al. J. Maternal - Child Health Needs Assessment in Haiti. Int J Appl Sci Technol.2014;4(5):30-38.
11. Bras A, Berdiera C, Emmanuelb E, Zimmermana M. Problems and current practices of solid waste management in Port-au-Prince (Haiti). Waste Manag; 2009:29;2907-2910.

12. Kligerman M, Walmer D, Merrell S. The socioeconomic impact of international aid: a qualitative study of healthcare recovery in post-earthquake Haiti and implications for future disaster relief. Glob Public Health. 2014;13:1-14.
13. Days for Girls International. Vision.
14. United Nations Commission for Women 2013 Reports.
15. McMahon S, Winch P, Caruso B, et al. 'The girl with her period is the one to hang her head'. Reflections on menstrual management among schoolgirls in rural Kenya. BMC Int Health Hum Rights. 2011;11:1-10.
16. Smith Jr, E V Wakely, M B DeKruif, R E L, Swartz, C. W. Optimizing rating scales for self-efficacy (and other) research. Educational and Psychological Measurement. 2003;63(3):369-391.
17. Sommer M. Where the education system and women's bodies collide: The social and health impact of girls' experiences of menstruation and schooling in Tanzania. Journal of Adolescence. 2010;33: 521-529.
18. Imade G, Sagay AS, Onwuliri VA, Egah DZ, Potts M, Short RV. Use of lemon or lime juice douches in women in Jos, Nigeria. Sex Health. 2005;2(4):237-239.

19. Kukulu, K. Vaginal douching practices and beliefs in Turkey. Cult Health Sex, 2006;8(4):371-378.
20. McKee MD, Baquero M, Anderson MR, Alvarez A, Karasz A. Vaginal douching among Latinas: practices and meaning. Matern Child Health J. 2009;13 (1):98106.