02 Rapport Menstruatie Armoede Midden-Groningen door studenten RUG

A Study on

Seizing Educational Opportunities to Combat Period Poverty in Midden-Groningen

Minor More Healthy Years: Current Challenges in Public Health BWMIN19

Coordinator: Prof. Dr. J. Fleer

22.01.2021

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Client Team

Student Team

Dr. Kristina Czura Assistant Professor, Faculty of Economics and Business k.czura@rug.nl

Lillian Balhuizen Biomedical Sciences, RUG l.h.balhuizen@student.rug.nl

Drs. Josine van ’t Klooster Faculty of Medical Sciences j.c.g.van.t.klooster@umcg.nl Mirjam Krans Armoederegisseur Gemeente Midden-Groningen mirjam.krans@bwri.nl Catherine Moughalian Faculty of Medical Sciences c.moughalian@umcg.nl Jolanda Oest Stafmedewerker Kwaliteit & Patiëntveiligheid bij Umcg j.j.oest@umcg.nl Dr. Susanne Täuber Associate Professor, Faculty of Economics and Business s.tauber@rug.nl Suzanne Oostvogels Regiomanager Zorg, Menzis oostvogels.s@menzis.nl

Pauline Breuer Health & Life Science, UCG p.breuer@student.rug.nl Marije Hofman Health & Life Sciences, UCG m.p.hofman.1@student.rug.nl Shanti Kok Life Science & Technology, RUG s.p.kok.1@student.rug.nl Lotta Rahlf International Relations and International Organisation, RUG l.rahlf@student.rug.nl

Mentors Dr. Marline Wilders Assistant Professor in Arts in Society / Empirical Research Methods Humanities, m.l.wilders@rug.nl Dr. Nadine Voelkner Assistant Professor in International Relations, n.m.t.voelkner@rug.nl

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Table of Contents 1. Introduction

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2. Discovery Phase

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1.2 Context 1.3 Structure and Research Questions 1.4 Methodology and Methods 2.1 Stakeholder Analysis 2.2 Picturing End-Users 2.3 Effects of Period Poverty 2.3.1 Health Risks 2.3.2 Absenteeism 2.3.3 Stigmatisation 2.4 Causes of Period Poverty’s Endurance 2.4.1 Financial Inaccessibility and Intervention 2.4.2 Educational Gaps, Lack of Awareness and Intervention 2.4.3 Taboos 2.5 Discovery Phase Conclusion

3. Define Phase

3.1 Choosing a Pathway 3.1.1 Pathway I 3.1.2 Pathway II 3.2 Personas and Customer Journeys 3.3 Problem Definition and HMW-Question

6 6 7

9 10 10 11 11 12 12 12 13 15 16

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17 17 18 18 20

4. Ideate Phase

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5. Prototype and Test Phase

27 27 28 29 29 30

4.1 Solution Visions 4.1.1 School Education 4.1.2 Social Media for Further Education and Awareness 4.2 Solution Package 4.2.1 Necessity and Feasibility 5.1 Social Media Education Research 5.1.1 Design of Prototype 5.1.2 Testing 5.1.3 Examining Thematic Preferences 5.1.4 Improving the Prototype

22 22 23 24 25

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5.2 School Education 5.3 Action Plan 5.4 Customer Journey

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31 32 33

6. Conclusion

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7. References

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8. Appendix

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6.1 Experience and Limitations

8.1 List of Stakeholders Contacted 8.2 Information on Interviews 8.3 Personas and Customer Journeys 8.4 Data from School Survey 8.5 Data from General Population Survey 8.6 Example of Policy Proposal

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39 41 42 48 50 52

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1. Introduction At least 500 million individuals out of the quarter of the world population who menstruate lack access to menstrual products because they cannot afford them (UNICEF, 2018; Boyce, 2020; Tull, 2019, p.3). However, the lack of economic resources to finance menstrual products is not the only reason for the existence of period poverty. The multifaceted phenomenon combines various poverty factors, including, but not limited to, access to sanitary facilities and crucially, education on menstruation (De Bovengrondse, 2019). From a human rights and gender equality perspective, researching and finding solutions to period poverty is long overdue.1 However, the amount of scholarly research is still small, and most interest has been devoted to period poverty in developing countries. Nevertheless, recent media attention to period poverty in the UK2 has given the Dutch public food for thought: Could period poverty also be a problem in the Netherlands? According to Plan International NL (2019), about 9% of 12-25-year-old females in the Netherlands could sometimes not afford menstrual products. While these figures clearly show a need for political action, the Dutch government continuously delegates responsibility downwards and reduces the problem to economic poverty (Bruins, 2020).

In order to create political awareness and solutions for period poverty in the Netherlands, more research seems urgently needed. Therefore, we investigated period poverty and its many facets in one of the poorest regions in the Netherlands, Midden-Groningen. We begin this report on our research project with a description of the context.

1 According to Human Rights Watch (2017), struggling to afford menstrual products causes situations in

which menstruating individuals cannot fully enjoy certain rights, such as those to education (Art. 13 ICESCR, Art 28-29 CRC, Art. 10 CEDAW), work (Art. 6-7 ICESCR, Art. 11 CEDAW) and health (Art. 11 CESCR, Art. 11 CEDAW). Furthermore, period poverty can be seen as a barrier to gender equality and a violation of the right to non-discrimination (Art. 5 CEDAW, Art. 5 CCPR). Holding the state accountable for violations of those rights caused by period poverty and suggesting legal interventions is however beyond the scope of this report. 2 Studies by ActionAid (2016, 2017),

Plan International UK (2017) and YoungScot (2018) on period poverty and menstrual stigma in the UK have attracted a lot of international media attention. Furthermore, the successful development of the “Period Products (Free Provision) (Scotland)” bill has attracted a lot of attention in 2020. 5

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1.1 Context Midden-Groningen is a municipality with a population of 60.953 people in the province of Groningen (Figure 1). As suspected in the beginning and later confirmed, the Aletta Jacobs College (referred to as AJC throughout this report) and the food bank Midden-Groningen stand out as particularly important locations for our research. Likewise, the alderman (referred to as the Wethouder throughout this report), Peter Verschuren, needs to be highlighted as an important local figure for our research. A relevant characteristic of this municipality is that the percentage of households below the low-income threshold is much higher than the Dutch average (see Graph 1). In its most impoverished areas, like Hoogezand-Zuid, child poverty has been increasing in recent years, with currently 1 in 5 children growing up in a household with low income. Compared to a decreasing national average of 1 in 12 affected children, this makes Midden-Groningen often the centre of political sorrow. The decision to use Midden-Groningen as a research case was furthermore based on the concerns of a citizen. Due to the above-average levels of poverty and eyewitness accounts, it is suspected that individuals in the municipality suffer from period poverty.

We want to test this assumption with our research and develop solutions to tackle period poverty in the Gemeente Midden-Groningen based on our results.

Figure 1: Gemeente Midden-Groningen

Graph 1: Percentage of households that live below the low income threshold for a minimum of 4 years, Source: Gemeente Midden-Groningen, Sociaal Planbureau Groningen (2018).

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1.2 Structure and Research Questions Reflecting our research process, the content of this report is divided into four sections. First, in the Discovery Phase, we conducted a problem analysis of period poverty in Midden-Groningen. We started by examining whether the underlying assumptions could be confirmed and asked: How are individuals affected by period poverty in Midden-Groningen? After establishing that there are severe effects that justify the development of solution-oriented interventions, we asked for underlying causes: Why are individuals in Midden-Groningen in this situation? The resulting desk and field research were then used to make a reasoned decision on our research direction and define a problem statement in the Define Phase. From this, our guiding question ‘How might we increase knowledge about menstruation and raise awareness for period poverty among high school students?’ emerged. Subsequently, we used the Ideate Phase to elaborate on solution options and combine them into a solution package. Finally, we tested a prototype and designed two policy briefs in the Prototype and Test Phase to prepare the implementation of our final solution. Graph 2 summarises the double diamond design process that underlies this report.

1.3 Methodology and Methods By researching the effects and causes of period poverty in Midden-Groningen, we want to determine the extent of the problem and the impact of contributing factors. Therefore, we used a mixed-method approach in our field research, combining quantitative and qualitative methods. In

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additional desk research, we consulted multiple scientific sources, such as peer-reviewed journal articles. Additionally, we used popular media, such as newspaper articles or social media trends, to understand current societal attention. In the Discovery Phase, the anonymity of quantitative surveys allowed us to gather numerous data on health effects, received education, taboos and awareness of period poverty, for example. Specifically, we distributed surveys to citizens of Hoogezand and school children from two high schools in the region. To understand general taboos and behaviours, we also surveyed the region’s general population.3 Absenteeism data provided by the AJC was also examined. However, we acknowledge the limitation of low response rates and potential bias in our survey responses. To balance this, we also used qualitative methods that have the advantage of understanding end-users’ experiences and stakeholders’ views. Such qualitative methods included many email inquiries and correspondence, telephone and online interviews with stakeholders, and field trips (see appendix: 1. List of Stakeholders Contacted). Furthermore, we gained crucial insights through five in-depth interviews with school children in Midden-Groningen.

Due to the Covid-19 pandemic, these interviews were conducted using GoogleMeet.4 Such qualitative methods were also preferred in the subsequent two phases of this research. However, in testing our prototype, we supplemented user feedback with an analysis of quantitative data on user engagement.

2. Discovery Phase In the Discovery Phase, we aimed to research the effects and causes of period poverty in Midden-Groningen. Our strategy was to find common claims in the existing academic literature (Figure 3) and check whether these could be verified in Midden-Groningen. We deliberately chose academic over popular literature since we expected the former to be less influenced by societal taboos. Before conducting desk and field research, we first analysed relevant stakeholders and imagined our end-users. Throughout our presentation of results, we also refer to insights gained from educational events that we attended during the ‘Perspectives Weeks’ and

3 Survey for Hoogezand citizens: 118 surveys distributed (response rate: 2.5%); Survey for high school

students at Winkler Prins and AJC: unlimited distribution, n=32 (3 students from a third school outside of Midden-Groningen); General population survey: unlimited distribution, n=152. 4 The interviews followed the ethical guidelines of the University of Groningen. The interview guide was

inspired by Hennink, M. Hutter, I., and Bailey, A. (2010). Qualitative Research Methods. SAGE Publications Ltd. For reasons of privacy, interviewees are anonymised. See appendix 2. Information on Interviews. 8

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relevant existing interventions. Ultimately, we conclude and reflect on our findings, as well as the remaining gaps in our knowledge.

Figure 3: Contributing factors and potential effects of period poverty

2.1 Stakeholder Analysis An analysis of stakeholders offered the first overview of possible research avenues. The following organisations or persons are of particular relevance to our project. If school education contributes to internalisation of taboos at a young age, and girls decide to skip school because of period poverty, local schools both have an influence and are influenced by the phenomenon in Midden-Groningen. This makes the AJC, the only high school in the municipality, a key stakeholder during research and potential future interventions. Demands for gender equality make period poverty a politicised topic as well. Therefore, local politicians are important stakeholders, as well. Because we expected a political reluctance in addressing taboo topics like period poverty, convincing politicians for our cause was considered crucial. At the same time, we hoped to benefit from political networks and contacts, some of which were already available through our clients. The local food bank is another stakeholder that is closely linked to period poverty. Donations of menstrual products reduce individual suffering, but the demands are hardly ever met in a donation-based system. This dilemma lent itself to a closer examination. Related stakeholders are also product companies and the general public.

The former have the potential to increase product access for individuals suffering from period poverty. The latter are important stakeholders for social awareness.

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Other stakeholders can be found on the labour market, since local employers are indirectly affected by work absenteeism due to period poverty, for example. Furthermore, adverse health effects resulting from period poverty may increase the burden on stakeholders in the public health sector, such as health insurance funds, general practitioners and psychologists. We initially saw an opportunity to investigate such effects of period poverty in contacting Menzis or the GGD. Because of this wealth of stakeholders, we sought to remain as open as possible to all research directions. This was also important for understanding the interplay of multiple stakeholders' motivations for (in)action as we learned in a health psychology workshop. However, our most important stakeholders are our end-users, whom we will now take a closer look at.

2.2 Picturing End-Users To carry out a solution-oriented problem analysis, it is necessary to deal with assumptions about end-users. We expected to narrow down our end-users during the research process but wanted to remain as open as possible at the beginning. Therefore, ‘Individuals in Midden-Groningen suffering from period poverty’ were broadly established as the group of people to be studied. Based on research from De Bovengrondse (2019) and our expectations, this category could include potential target groups like food bank customers, the homeless, refugees, or families living on a budget of less than € 50 / week more generally. A hypothetical scenario where an end-user is affected by period poverty could be seen in a lowincome household in Hoogezand. While the teenage daughter is too ashamed to ask, the singlefather does not understand his daughters’ needs for menstrual products nor has the financial means to buy them. Such a scenario also matches concerns of the AJC headmaster about period poverty among her students. A look at insurance data provided an initial overview of the possible number of people affected. 828 women currently have the aanvullende zorgverzekering, and in response to our inquiry, we learned that 288 of 16-45- year-old women in Midden-Groningen currently have a gemeentepolis from Menzis.

2.3 Effects of Period Poverty There are several effects associated with period poverty, such as health risks, absenteeism and stigmatisation. In our field research, we investigated their occurrence in Midden-Groningen. For

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reasons of clarity, we will give a summary here. A full analysis can be found in our discovery report.

2.3.1 Health Risks According to some scholars, suffering from period poverty leads to adverse health effects such as a higher risk of Reproductive Tract Infections (RTI) or disruption of vagina floral balance (Hoffman et al., 2014; Torondel et al., 2018).5 After contacting a UMCG gynaecologist and 16 practitioners and psychologists in the area, we could not confirm these effects in MiddenGroningen6. However, it must be stressed that the possibility of getting infections will remain. Some women might be ashamed, unaware of infections, or do not see the importance of contacting a doctor.

2.3.2 Absenteeism Claims of a relationship between period poverty and school/work absenteeism are popular but highly debated.7 Respondents from the school survey and interviewees confirmed that absenteeism is mainly due to menstrual symptoms.8 Furthermore, we believed to see a pattern in girls school absenteeism data.9 However, more data is needed to support this assumption. Even though we could not find any evidence, some students may be affected by period poverty but did not want to admit having problems or felt uncomfortable filling in the survey.

5 Due to the limited number of research, this relationship is still debated in the literature. See for example

Sumpter & Torondel, 2013.

6 The gynecologist nevertheless mentioned the rare possibility of Pelvic Inflammatory Disease or sepsis

resulting from infections with group A streptococcus and one psychologist explained that period poverty can have a negative impact on mental health. 7 Because some studies do not find a relationship between girls’ school attendance and increased product

provision (see Oster & Thornton, 2010; Oster et al., 2012), absenteeism could relate to period symptoms instead (Ichino and Moretti, 2009). However, anecdotal evidence from Scottish schools, for example, suggests some relationship (Lennon, 2017). 8 50% of the school survey respondents (N=32) reported to have missed school days because of menstrual

symptoms. There were no indications of missed school days because of product inaccessibility.

9 Female absenteeism data, covering a three month period (September - November 2019) received from

the AJC.

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2.3.3 Stigmatisation Individuals affected by period poverty and the process of menstruation are believed to be stigmatised, partly due to the framing of individuals or products as we learned in a workshop on moralities. The school survey results suggest that respondents have high leaking fears in public (MV=7.14) compared to leaking at home (MV=2.4). Furthermore, 75% of the respondents (n=32) reported feelings of dirtiness/discomfort while menstruating. Finding empirical evidence of period poverty was challenging since signs are often kept hidden out of shame. However, even the partial evidence for these effects in Midden-Groningen underlines the necessity to tackle period poverty in the municipality. Therefore, we now turn to the causes of this phenomenon.

2.4 Causes of Period Poverty’s Endurance 2.4.1 Financial Inaccessibility and Intervention Due to the widespread definition of period poverty as the lack of financial resources to access menstrual products, poverty is widely considered its primary cause. Our research confirms this: With 30-40 women asking for diapers or menstrual products at the food bank per week, many individuals in Midden-Groningen seem unable to afford menstrual products.10 Furthermore, teachers reported students’ demand for menstrual products but experienced abuse of free product provision. As the pandemic made it challenging to meet those in need, we ultimately resorted to survey data. However, since only one respondent knew someone affected, we turned our research interest to more social causes of period poverty’s endurance. However, one of our clients developed a product-access intervention: Since the local food bank’s workload even increased due to the pandemic, Jolanda Oest started her second ‘Bloedserieus’ campaign in October. Until the end of 2020, she collected menstrual product donations weekly at local stores and community centres for the food bank.11 However, despite their success, such individual voluntary projects are no substitute for long-term solutions.

10 At the same time, free supply of menstrual products is rare. We contacted one company (Essity) and four

supermarkets (Lidl, Aldi, Jumbo, Action) and were mostly turned away. Campaigns like the recent collaboration of Always, Kinderhulp and food banks (September - November 2020) are rare exceptions.

11 Other mentionable interventions to tackle problems with product access include the free provision of

menstrual products in public places and on educational sites (e.g. Scotland, New Zealand), the period-card scheme (proposal in the UK), or online communities. See our discovery report for more information.

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2.4.2 Educational Gaps, Lack of Awareness and Intervention The lack of knowledge surrounding menstruation and period poverty is believed to be a crucial social factor contributing to period poverty’s endurance. Insufficient menstrual education has multiple impacts, not only on gender relations (UNESCO, 2014) but also on family relations, with menstrual education often being left to mothers (Coast, Lattif & Strong, 2019). If education is insufficient and girls never learn ‘what is normal’, diagnostic delays or handling of period poverty that is hazardous to health can result (De Bovengrondse, 2019). Both teachers and students agreed that increased education would normalise conversations on menstruation, which would increase donations and make asking for products a less uncomfortable experience. This is the basis for another example of intervention against period poverty: After advocacy from Plan UK to include biological, physical, emotional and social aspects of menstruation in schools, menstrual health entered the curriculum in 2020 (BBC, 2019). Although not all demands were met, this educational intervention shows a political awareness of the need to expand menstrual education, which may also be achievable in the Netherlands.

After an interview with Jelle Wiering on Dutch sex education, we already expected gaps in Dutch menstrual education and a meeting with teachers of the AJC confirmed this. Two surveys provided us with unexpected insights on menstrual education in the Netherlands and among school children in Midden-Groningen. As Graph 2 shows, while 87.3% of Dutch respondents (n=71) reported education on menstruation’s biological aspects, this was still the only type of menstrual education received for 11.3%. Furthermore, compared to German or international respondents, the Dutch scored worse on menstrual health (12.7%) and TSS (16.9%). Interestingly, the school children survey in Midden-Groningen showed a different picture (Graph 3 on the next page). Here, only 46.88% (n=32) reported education on menstruation’s biological aspects. An explanation could be that VMBO-level students do not receive any menstrual school education, as we learned from teachers. In-depth interviews with school children confirmed trends that the survey results suggested. All interviewees had only learnt about the biological aspects of menstruation. Most deal with this lack of school education by educating themselves using social media, the internet or asking family members.12 Additionally, all interviewees showed a desire for more education, to which we return later.

12

Corresponding to the literature, all female interviewees sought advice from their mothers. 13

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Graph 2: Received Education on Menstruation, Data from General Population Survey (n=152).

Graph 3: School Children: Received Education on Menstruation, Data from School Children Survey (n=32).

The surprise of these educational gaps and our own experiences with some peers’ and stakeholders’ restrained enthusiasm led us to make a small digression on problem awareness. Participation in a lecture on health communication further encouraged us to understand different motivations for (in)action in this way. Our assumptions of low awareness of period poverty’s existence in the Netherlands and its effects were confirmed both by our survey results (Table 1) as well as our interviews. Interestingly, most interviewees were surprised to hear of period poverty

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in Midden-Groningen, although one female suspected girls at her school suffered from period poverty.

Table 1: Awareness of period poverty and its effects, Data from General Population Survey (n=152).

2.4.3 Taboos Related to education and awareness of period poverty is a unique combination of taboos (NL Times, 2019). Even in the supposedly progressive Dutch society, open conversations about menstruation are rare or euphemisms are used (Kissling, 1996). As we noticed in an artistic workshop, advertisements reflect and promote these taboos. The consequences are a nonthematisation of period poverty, female insecurities about correct handling of menstruation or even a negative attitude towards the female cycle (Forbes et al., 2003; Grabinsky, 2019; Johnston-Robledo et al., 2013). Likert-scales and experienced levels of cooperation provided us with insights on menstrual taboos. Our school survey results show that talking about menstruation is still perceived as uncomfortable (Graph 4). The difficulties we experienced in arranging interviews with students and the low response rates to the surveys additionally indicate discomfort when talking about the menstruation. However, little interest in interviews might also be influenced by the online setting. Furthermore, we initially planned to hand out surveys at the food bank, but many customers indicated that the questions were too personal, resulting in a decision to cancel the distribution. Jolanda Oest also noticed this discomfort, because some food bank customers were ashamed to ask for menstrual products.

As the following example shows, we also noted an unexpected gender difference concerning taboos underlining the necessity for tackling taboos from a gender-equality perspective. Interestingly, also all female interviewees expected males to laugh at a woman with a bloodstain. However, when asked to describe a menstruating woman in one word, all insulting responses were from females.

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Graph 4: Levels of discomfort when talking about menstruation, Data from School Children Survey (n=32).

Figure 4: Statements made by interviewees.

2.5 Discovery Phase Conclusion Our desk and field research confirms the initial concern that period poverty is a problem in Midden-Groningen that requires urgent attention and intervention. Regarding our first research question which asked for effects of period poverty in the municipality, we have looked for adverse health effects, school/work absenteeism and stigmatisation and found partial evidence in Midden-Groningen. Due to the current pandemic and taboo surrounding the issue at hand, it was challenging to contact individuals suffering from period poverty directly. The resulting gaps in knowledge needed to be filled during other research phases. Regarding the second research question that concerned the causes for period poverty’s endurance, we established poverty to be the phenomenon’s primary cause but turned to social factors contributing to its persistence. Knowledge gaps regarding menstruation, lack of awareness of period poverty and culturally 16

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produced taboos were highlighted and identified as unexpected but highly relevant findings. We shared these results with our clients who had already suspected difficulties in empirically studying and quantifying the problem. Nevertheless, they welcomed the many perspectives we included in our problem analysis and encouraged us to decide which path to follow for the next research phases.

3. Define Phase 3.1 Choosing a Pathway In the Define Phase, we reflected on our insights from the Discovery Phase and decided on our project’s future direction. Based on a reasoned decision, we then narrowed down our end-users in a process of re-adjusting our initial expectations through dialogue with end-users and clients. The resulting personas and customer journeys facilitated a problem definition and the formulation of a ‘How-Might-We-Question’. During our desk research, we identified inaccessibility of products, lack of knowledge, and culturally produced taboos as contributing factors to period poverty. From this, two pathways follow, each suggesting different courses of action. Wanting to pool our resources effectively, we made a reasoned decision on which pathway to follow.

3.1.1 Pathway I A prevalent definition of period poverty defines it as the lack of financial resources to access menstrual products. This implies that interventions need to focus on facilitating product access. Although problems to finance menstrual products could be the leading component of period poverty in Midden-Groningen, our field research could only find partial evidence. However, our tentative findings regarding product accessibility, such as concerns of food bank volunteers, can inspire further research. Especially citizens’ discomfort regarding the topic impeded gathering more empirical evidence. On the one hand, future long-term research in low-income areas like Hoogezand-Zuid may enable researchers to establish necessary trust levels to research such taboo topics. On the other hand, such experience suggests that period poverty should not be reduced to product inaccessibility at the expense of socio-cultural factors. This corresponds with

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some scholars’ criticism of interventions that only focus on product access and thus oversimplify a “complex socio-cultural” problem (Bobel, 2019, p.9). Having reflected on the limits of our research and seeking to avoid simplification, we ultimately decided against this pathway.

3.1.2 Pathway II An alternative definition of period poverty accounting for socio-cultural factors seems more appropriate for us. This also corresponds to the unexpected evidence on the lack of menstrual knowledge in our field research. Accordingly, period poverty can also take the form of knowledge poverty. This can firstly refer to a lack of knowledge on menstruation. Our survey among school children confirms knowledge gaps in multiple aspects of menstruation. Unfulfilled learning needs can be found in biological aspects, menstrual health, practicalities, and socio-cultural aspects of menstruation. The extent of menstrual knowledge obtained at a young age determines how individuals handle period poverty. Learning about health risks may prevent individuals suffering from period poverty from resorting to alternative products. Secondly, knowledge poverty can refer to a lack of awareness of period poverty. Our survey on the general public confirmed this. If society and especially policymakers do not know about period poverty, let alone its existence in the Netherlands, they will not contribute to a solution. Given our empirical findings regarding insufficient menstrual education and lack of awareness of period poverty, we feel motivated to tackle these factors.

Furthermore, following the educational and awareness pathway may even lay the foundation for product access interventions. Having chosen this pathway, it is now time to zoom-in further and imagine potential end-users by creating personas and customer journeys.

3.2 Personas and Customer Journeys In the Discovery Phase, we defined our end-users as individuals in Midden-Groningen affected by period poverty. However, due to our decisions, we need to concretise this definition. Our educational approach makes school children, whether affected by period poverty or not, our primary end-users. However, the chosen pathway is also about long-term social awareness of period poverty. Therefore, the public at large can be considered a secondary end-user. The following personas and customer journeys are the product of a continuous readjustment process

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based on communication with our clients and our observations from in-depth interviews with school children.13

Emma is an ambitious VMBO student at AJC and has a passion for dancing. Most of the time, she practices at home, as her family cannot afford ballet class. Besides dancing, she enjoys spending time with friends. This morning Emma got her period again. She is stressed out because she knows that her lowincome family is always short on period products. Because the thought of leaking at school terrifies her, she decides not to go to school and meet her friends today. Instead, she stays in bed, feeling insecure and anxious.

Sara is a VWO student at the AJC in Hoogezand. Being an optimistic and diligent person, she dreams of becoming a teacher. She lives together with her financially stable parents. Last week, Sara learned about reproduction and the menstrual cycle in biology class. Although she did not learn anything about the use of menstrual products, related health issues, or the socio-cultural aspect of menstruation, she feels sufficiently educated. Tampons and pads seem to be the most common menstrual products for her. However, being a busy student, she infrequently changes her menstrual products, causing her occasional discomfort (she is unaware 13 See appendix for a full version of personas and customer journeys.

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that she suffers from minor infections). Sara also has a friend who skips school when she is on her period or keeps on “forgetting” products without telling her the reason. Sara is confused by her friend's behaviour, as keeping products in the school bag is “common sense” to her.

Milan Dijkstra is a 24-year-old Dutch student. He went to school in Midden-Groningen but currently studies law at the RUG. Being a member of a student organisation, he has a strong social network, and he seeks to give the impression of a down-to-earth, emancipated young man. In line with this, he occasionally engages in welfare work with his friends and documents such activities on social media. For 10 minutes, Milan has been absorbed in his phone. He has just read a trending Instagram post about period poverty, something he had never heard of. He is shocked by the information that this is a problem in his home-town, Midden-Groningen. Although the topic makes him a little bit uncomfortable at first, this quickly turns into a sense of guilt: Why does he know so little about this problem? When he reads that he can donate menstrual products to the local food bank, he is relieved. Not only does he feel better about himself now, but telling his friends about his actions also boosts his confidence.

3.3 Problem Definition and HMW-Question Having narrowed down our research and empathised with end-users using personas and customer journeys, we are now able to state the following problem definition: There is a lack of menstrual knowledge and awareness of period poverty in the Netherlands. Education tends to be limited to the biological aspects of menstruation, thereby neglecting sociocultural elements. Instead of discussing menstruation within the syllabus, it is only discussed by

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some teachers after a related ‘accident’ occurs. This exemplifies that the students only receive education when the situation demands it and not in a consistent and controlled manner. If individuals lack knowledge about period poverty and menstruation, this negatively impacts their health in multiple ways. Not knowing of existing diseases, health complications, and practical aspects of menstruation (e.g. product types and treatment of period symptoms) may increase the vulnerability to infections or menstruation-related diseases, like in the case of our persona Sara. Furthermore, if education is reduced to biological aspects of menstruation only, the topic is abstracted from daily experiences, aggravating open conversations. Individuals suffering from period poverty, such as Emma, might consequently refrain from seeking help and the shortterm stress caused by this experience may develop chronic anxiety. As Milan’s customer journey shows, this problem is not limited to the school environment, since it has long-term societal implications. What is learnt and not learnt in school, especially at high school, will be reflected at the societal level.

The lack of knowledge about period poverty and menstruation results in a lack of social empathy: As our field research confirmed, there is currently little stimulus to think of possible effects of period poverty in daily life and thus no motivation to seek a collective solution as a society. Accordingly, a sustainable solution to period poverty needs to start with enhancing knowledge about menstruation and awareness of period poverty, ideally already at high school. Specifying this aim even further, we let the following question guide us through the next research phases: How might we increase knowledge about menstruation and raise awareness for period poverty among high school students?

4. Ideate Phase The goal of the Ideate Phase was to decide on a final and impactful, yet feasible solution to this HMW-question. In order to do so, we first developed two solution visions. Then, we summarised our ideas in a solution package to concretise these visions together with input from clients and related stakeholders. Initially, we collected multiple ideas before deciding on the ideal solution and evaluated these according to the criteria of practical feasibility, cost-effectiveness and end-user needs. For 21

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example, we considered incorporating menstruation and period poverty topics into the existing school curriculum. However, each school’s freedom concerning teaching format and content may increase taboos and therefore, end-users’ needs cannot be met. To prevent this, another idea was to use existing external providers of menstrual education. Schools could invite these providers to give quality-assured lessons on menstruation. Since the AJC and the government of Midden-Groningen stated that they would not appreciate external parties interfering in local affairs, we also ruled out this option due to the lack of practicability. Lastly, to make the educational content accessible for a larger audience, we saw great potential in using informational websites. This solution was also rejected after a cost-benefit analysis. The costly creation and maintenance of a website do not pay off with the expected effects.

4.1 Solution Visions In multiple brainstorming sessions, we asked ourselves how we might ideally close existing knowledge gaps and create more awareness of period poverty. Finally, we decided on the following two visions:

4.1.1 School Education Ideally, all Dutch school children should receive an all-encompassing menstrual education. School is an attractive setting for this since lessons can be tailored to fill the identified gaps in knowledge and directly address school children’s educational needs. Furthermore, next to menstrual knowledge, students can also be taught empathy and donating behaviour. Our research has indicated that there is a need for action here as well. Lastly, lessons may also be research objects themselves and thus continuously improved: Learning outcomes can be measured and learning content evaluated and adapted where necessary. To make such a vision reality, some basic requirements must be met. After learning that there are no school lessons on menstruation offered in the Netherlands, we realised that such new lessons would need to be added to the curriculum. As our clients point out, this is only possible if such lessons have been scientifically tested beforehand, meet quality standards and exhibit demonstrable learning success. Furthermore, this solution would also need to be standardised nationally or be available to schools free of charge or at low cost as an external offer. Lastly, teachers must have received the necessary training to prevent backlash effects, such as unintentionally increasing taboos.

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However, this vision alone is no satisfactory answer to the HMW-question. Such educational solutions will only address our primary end-users, school children, thereby only improving menstrual knowledge in society in the long-run. Furthermore, depending on the quantity of these lessons, the risk remains that children who feel uncomfortable or ashamed decide not to attend them.

4.1.2 Social Media for Further Education and Awareness Another vision focuses on virtual education. For example, social media is a popular virtual context for knowledge creation, with 84% of Dutch teenagers regularly engaging in social networking (Statista, 2019; Dron and Anderson, 2014). Our Interviews with teenagers confirmed our assumption that using social media for educational purposes is perceived as more modern and innovative than traditional school lessons. Quizzes and challenges can be added to platforms, stimulating users to learn more and test their knowledge. Being easily accessible for anyone, educational content will also reach beyond the classroom: In this way, knowledge gaps of today’s society, not just tomorrow’s, could be closed. The anonymity of this virtual context may also invite more open conversation on experiences with period poverty. Ultimately, also this vision is dynamic: User behaviour can become a research object, and social media content is adaptable to identified users’ needs. A hypothetical implementation of such a vision would also be easier than a curriculum change. Once the content has been created, and a provider has been found, only a large number of followers have to be generated to ensure proper working of social media algorithms. This can be facilitated by promoting such platforms in various ways.

However, this vision also has its limitations. After all, social media use is voluntary. Individuals who do not actively seek or want to find educational content on menstruation and period poverty on social media will only be addressed by chance. This is particularly regrettable since many are still not convinced of the necessity to tackle period poverty. Furthermore, nobody can be expected to take advantage of every virtual learning opportunity. Therefore, the learning effect for members of society who no longer receive school education may be less than hoped. Since menstruation is largely considered a sensitive topic, some individuals may also prefer a personal conversation, especially about menstrual taboos and period poverty.

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4.2 Solution Package While both of these visions undoubtedly have potential, neither constitutes an impactful answer to our HMW-question as an individual solution. Therefore, we decided together with our clients and mentors to make a solution package. Our goal is to develop an original solution that addresses the educational needs of both our primary end-users, school children in Midden-Groningen, and of our secondary end-users, members of society. Both types of end-users have knowledge gaps regarding menstruation that need to be filled and a lack of awareness of period poverty. Only combining physical and virtual education can achieve this goal. School education should lay a knowledge foundation for life. If school children receive an allencompassing menstrual education as we envisioned, then females will understand how to deal with their menstruation safely and healthily, which may decrease female school absenteeism or the risk of self-inflicted adverse health effects. Furthermore, a taboo-free safe space may be created to share experiences and discuss problems. As teachers point out, such a safe space is needed to encourage children to voice their needs. At the same time, students sensitised for period poverty may develop a desire for long-term eradication of the phenomenon and increasingly see themselves as part of its solution.

Social media are both a supporting factor and a solution component in its own right. In general, it makes sense for practical reasons to integrate social media into the classroom. On the one hand, this would promote more interactivity: Our peers mentioned ideas of contests and challenges, for example, that could be initiated and guided by social media. On the other hand, available tools such as quizzes can regularly measure students’ learning outcomes and enable adaptation of educational content to individual learning needs. This is especially important since different school levels may require different learning approaches. Besides, teachers agree that educational content on social media is also a possibility for further voluntary education. Students who want to continue learning may use educational social media to get and exchange information. In this way, our second vision balances out the shortcomings of the first. The anonymity of virtual learning allows students to have a shame-free learning experience. Furthermore, educational social media content is also freely available for our secondary end-users, members of society. Although use is voluntary, goals like broader societal awareness of period poverty will be achieved. Importantly, the unrestricted availability of social 24

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media education must be highlighted. Menstruation or period poverty is experienced mostly outside of school. At times, information needs to be available on-demand and enable “here and now learning” (Martin and Ertzberger, 2013, p. 77) to make decisions in a real-life context (Lave, 1988). As already indicated in our problem statement, menstrual education, let alone an allencompassing one, is not yet part of Dutch school curricula. Midden-Groningen could lead the way and become the first municipality to educate its youth and citizens in such an original and innovative way. A look at end-users’ needs, habits, and teachers’ feedback will provide further insights into this solution’s necessity and feasibility.

4.2.1 Necessity and Feasibility First, we see a great demand for more comprehensive menstrual education. According to the Menstruatie Voorlichtingsinstituut, 80% of 15.000 Dutch girls between 12-19 would like to have more information about menstruation (De Bovengrondse, 2019) and all interview participants showed a desire for more comprehensive menstrual school education. A student at AJC also stressed that she would have liked to receive basic information on menstruation at school before educating herself online. Teachers especially highlighted the need for more menstrual education to remove taboos and also confirmed the feasibility of including menstrual education in schools, provided they have been tested. Second, in line with our findings from the Discovery Phase, our school survey showed that the internet is more often mentioned as a source of knowledge on menstrual product use, menstrual health, or TSS than teachers (Table 2). A similar phenomenon can be seen with the awareness of period poverty (Table 3). While these statistics show apparent deficiencies in school education that need to be addressed, they also display the opportunity that social media presents for our goals. Our clients also believed that social media is a great way to reach a large audience, but that such virtual education should not be limited to one platform.

Usage of multiple social media platforms must be considered to reach users with different preferences. In addition, magazines or short articles can inform individuals who do not use social media at all. However, this could be a possible idea for the long term, once social media has reached a certain amount of people and sparks interest in the other media platforms.

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Sources to Gain Awareness of Period Poverty Books

Family

Teacher

Internet

Friends

13.3%

40 %

87 %

26.7 %

-

Menstrual product and their use

-

73.9 %

8.7%

52.2 %

17.4 %

Menstrual health

-

50 %

12.5%

75 %

-

TSS

-

50 %

10 %

60 %

20 %

Biological process of menstruation

Table 2: Sources to gain knowledge about menstruation-related topics. Data from School Children Survey (n=32).

Sources to Gain Knowledge About Menstruation-Related Topics Friends

Family

Social Media

News

Internet

Documentaries

19.3%

12.3 %

22.8%

15.8%

15.8%

15.8%

Table 3: Sources to gain awareness of period poverty. Data from General Population Survey (n=152).

Having discussed two ideal visions from our brainstorming process and combined them into an original solution package that reflects our end-users’ needs, we are now able to formulate an answer to our HMW-question: A combination of school and social media education may fill the existing gaps in menstrual knowledge and raise awareness of period poverty among high school students. In the next phase, we determine what we can contribute to this solutions’ implementation.

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5. Prototype and Test Phase The Prototype and Test Phase’s goal was to determine how our solution package of combined school and social media education may be implemented. We first address the idea of social media education, since this plays a role both within school lessons and independent from them. A prototype of a social media page was designed, and user engagement with this prototype analysed. This way of testing offered us preliminary insights into user preferences on thematic categories, which helped us improve this prototype. Next, we looked at what is required to implement school lessons on menstruation and period poverty and explain our political actions and ambitions. Lastly, we exemplify how an end-user will benefit from the implementation of our solution package using a service scenario.

5.1 Social Media Education Research “Testing is just another form of research (...) (It) ensures that the design becomes more and more focused toward getting it right” (Baer, 2008, p.78) Because we wanted to gain first insights into how young people react to information on the thematic areas that we have found knowledge gaps in, we designed a prototype of an educational social media page on Instagram.14 Over a month15 we published 1-2 posts daily from different thematic categories, which we based on our end users’ identified learning needs: Period health, period products and their use, and information on period poverty. We also followed our peers’ recommendation to add challenges to test whether end-users’ would favour interactive learning methods. We started our testing process, assuming that users engaging with our prototype would have similar knowledge gaps and learning needs that we identified in the Discovery Phase. Furthermore, due to the popularity of Instagram, we expected to reach a large audience and that users will feel comfortable with the simple design and ease of use in a virtual context they are already familiar with. Particularly, we assumed that users would react positively to posts on period health since we identified the greatest knowledge gaps here.

14 Our Instagram page prototype can be accessed via this link: https://www.instagram.com/period.jungle/. 15 Time period for testing: 31.11.2020 - 31.12.2020.

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5.1.1 Design of Prototype Since this was considered appealing to our target audience, all educational posts had a comicstyle design and the informational texts were provided in English and Dutch. To increase the outreach of this social media page and upon client recommendation, we also used available tools, such as hashtags or links to popular profiles. Most content was obtained from reputable internet sources.16 To test knowledge and build in interactivity, we ultimately included quizzes and examined how users’ react to virtual knowledge assessments.

5.1.2 Testing We tested our prototype to determine the value of Instagram as a social media opportunity for menstrual education and period poverty. Furthermore, testing served the purpose of continuously improving our prototype to make it employable both within school lessons as well as

16 Examples of such sources are the NICHD, Mayo Clinic, or Planned Parenthood.

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independently. Improvements were made based on collected data on user behaviour and preferences over four weeks17 and individual feedback.

5.1.3 Examining Thematic Preferences According to our data analysis, content on period poverty was liked the most, including and excluding content that was promoted externally, while content on period health was liked the least (Graph 5).

Graph 5: Average amount of likes per theme, Data collected by research team over four weeks.

However, the difference in the average number of likes could also be explained by the fact that period poverty-related content was viewed more often or that a comparably larger number of such posts were shared early on. This insight suggests that Instagram may be better suited for raising awareness than for in-depth education. However, this result strengthens our argument as it shows that school education is highly needed and that social media has nevertheless potential to create awareness beyond the classroom. At the local level, this can be particularly beneficial: 17 We monitored the daily amount of followers, the development of likes per post (Days 1-4, Day 7), the total

number of times a post has been seen and individual posts’ comments (Day 1, 3). 3 and 7 days after a post had been published we also noted the number of times period.jungle was visited, the number of unique accounts that have seen the post, the number of accounts that started following period.jungle and the percentage of accounts reached that were not following period.jungle. A full list of data can be requested. 29

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Interestingly, an informative post on Jolanda Oest’s Bloedserieus campaign had

the most

views.18

5.1.4 Improving the Prototype In addition to data analysis, we considered feedback from followers for the prototype’s improvement. Most of the individuals who provided feedback were aged 20 and either from the Netherlands or living in Groningen. The professional, similarly designed posts, and the regularity of posting were highlighted as assets of our prototype. Moreover, statements about surprised reactions to our period povertyrelated content confirmed the awareness-raising potential of social media. Through constructive feedback, we found opportunities for improvement that we could include into the testing phase. For example, we have complied with the request to provide more information on the answers for quiz questions from the first testing week onwards. We also followed the suggestion to create several pictures with information per post and were thus able to present educational content more attractively. A significant change was the introduction of a ‘Linktree’19 which made it easier for users to reach different sources. A follower inspired us to add an anonymous feedback quiz. This gave us an impression of user preferences in addition to our data analysis. The results confirm our previous findings: For example, 71% of respondents preferred content on period poverty over challenges (29%), and all wished to have more quizzes.

Additionally, 82% of respondents said that they learned something from our Instagram page over one month. Such feedback shows us that social media can also fulfill an educational function. The supportiveness of our clients about using Instagram as an education tool remained. They attempted to get in contact with Dutch influencers to increase outreach, but this was unsuccessful. Instead, we decided to reach out to similar pages, acquaintances and the university newsletters to promote our page, which was more successful.

5.1.5 Maintenance of Social Media Education 18 Due to limited space, we had to limit our analysis of Instagram data in this report. Please contact us for

further information or data.

19 Linktree is a tool used to link multiple sites through a single link.

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The improved prototype is now ready to be used for educational purposes. Since our final solution is a combination of school and social media education, we focus here on the use of this prototype for our primary end-users, school children. Therefore, we will look at the implementation of the prototype in school education in the next step. However, it should be said that an NGO is needed to manage the platform and regularly share content in the long-run. NGOs tend to have the means to professionally test user behaviour and interests, which is needed to improve the content and the way information is communicated to society.

5.2 School Education All-encompassing menstrual school education would use social media resources, such as our prototype, to test students’ learning outcomes and encourage their use for further voluntary learning. However, our clients have reminded us that we are not qualified to prototype and test such lessons as undergraduate students. Nevertheless, testing prior to implementation is needed. Therefore, our mentors and clients support the idea of making two political proposals to set processes in motion that we are not allowed to carry out ourselves. Our first proposal is addressed to the AJC. Using our research findings, we will convince the headmaster to establish a multidisciplinary team to test a menstruation lesson pilot. In a second proposal, we ask the Wethouder of Midden-Groningen to support this pilot financially and establish cooperation with stakeholders, like the GGD. These proposals were initially prototyped and subsequently tested and improved through feedback. Thanks to a committed politician’s effort, we could discuss our ideas with teachers from the AJC and the Wethouder. Thereby, we were able to increase the chances of our proposals’ success. The Wethouder assured us that the municipality could offer funding opportunities and assist with establishing contacts. The AJC teachers confirmed that such a pilot could be tested and evaluated at their school.

They also welcomed the funding possibilities through the municipality and political leverage.

5.3 Action Plan The implementation process is just beginning with these proposals. While our goal within this minor is to convince the aforementioned stakeholders and set the testing process of a menstruation lesson in motion, we would like to see our proposal fully implemented in the longrun. For the best results, a team of experts and motivated people is required. Although the AJC teachers would prefer a school-internal pilot, support from health professionals (e.g. GGD), or researchers from the Aletta Jacobs School of Public Health may be useful for learning content

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and methodology. The Wethouder and possibly the City Council may help finance the pilot if the political will is there. Following the approval of our clients, the motivation of all stakeholders is necessary for success. Headmasters must be convinced of such a pilot's necessity, and teachers must be motivated to make a change. Although it is not mandatory, action from the municipality to fund the pilot is beneficial. Related to these factors of success are potential challenges. We already experienced that period poverty is often cast aside as unimportant due to social stigma. We hope to convince stakeholders such as headmasters, who may meet our ideas with resistance, of the urgency for action by presenting our research. Despite the Wethouders’ assurances, argumentation skills regarding financing are likely to be required. Nevertheless, we are confident that the following steps can be implemented: First, Jolanda Oest will present our policy recommendations to the college of Burgemeester and Wethouders and upon client confirmation, two policy briefs will be sent to the AJC and the Wethouder, respectively. Ideally, the headmaster of the AJC would be convinced by our findings and create an expert group to prepare and conduct the pilot. The municipality of MiddenGroningen would offer funding opportunities and establish contact with the GGD to provide optimal framework conditions.