Centring participant experience: a realist evaluation of a menstruator-friendly facility design project in a refugee settlement, Lebanon

(2024) 24:170 Hales et al. BMC Women’s Health https://doi.org/10.1186/s12905-024-02961-z BMC Women’s Health Open Access RESEARCH Centring participant experience: a realist evaluation of a menstruator‑friendly facility design project in a refugee settlement, Lebanon Georgia Hales1*, Paul Hutchings1, Katy Roelich1, Mahua Das1, Alexandra Machado2, Debora Bonucci3 and Farah Salem1 Abstract Introduction Menstrual health in humanitarian contexts is a neglected topic. Its taboo nature presents difficulties for participants in menstrual health projects in these particularly challenging settings. Namely, their experiences may be concealed or overlooked in projects that are typically outcome focused. Realist Evaluation is a useful method to unearth and explore the hidden mechanisms and their causes, which lead to positive or negative participant experiences. The authors have applied this approach to a robust humanitarian menstrual health project to explore how to centre the emotional wellbeing of participants at all stages: prior to, during, and post-participation. Study setting The project studied was led by the International Federation of Red Cross and Red Crescent Societies who piloted their adaptable manual for menstruator–friendly water, sanitation and hygiene (WaSH) facility design in humanitarian contexts. It was conducted by the Lebanese Red Cross in an informal tented settlement hosting Syrian refugees in Qaa, Lebanon. Methods The authors collected interview and focus group data on the contextual factors and processes within the project from nine project staff and 16 settlement inhabitants. They used a realist process of theory development, testing, and consolidation to understand how and under what circumstances the project inputs affected participants’ wellbeing. Results The contextual factors and causal mechanisms promoting participant experience comprised individual (choices influencing and experience during participation), interpersonal (group dynamics and the role of non-menstruators), and organisational (expertise and knowledge, relationship to participants and cultural differences) factors. Implications The research uses a case study from a renowned humanitarian organisation who provided a well-delivered project in a conducive environment to explore the mechanisms and contexts that can promote wider learning and refine understanding and programming in this under-researched and -theorised space. Specifically, it informs which contextual factors and project inputs must be present within a menstrual health project to ensure participant satisfaction whilst efficiently delivering well-designed menstruator-friendly WaSH facilities. Keywords Menstrual health and hygiene, Lebanon, Refugee settlement, Realist evaluation, Participation, MHMfacility design *Correspondence: Georgia Hales Full list of author information is available at the end of the article © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hales et al. BMC Women’s Health (2024) 24:170 Terms To be inclusive of gender diverse persons Hennegan et al.’s [9] definition of menstrual health for policy, practice, and research defines those who have the ability to menstruate as ‘menstruators’ and those who do not as ‘non-menstruators’. A significant shift in collective language will pose challenges. In the United Kingdom (UK) Dahlen [4] writes how gender-neutral terminology in medical literature faced backlash in fear of the erasure of women’s needs. Different cultures have varying views on gender identity meaning some languages may not offer gender-neutral terms or be able to translate new terms from one language to another. Thus, identifying menstruators and non-menstruators across different humanitarian settings may result in people being left out. To avoid this we can use gender-additive language where both gendered and gender-neutral language is used e.g. ‘women, girls, and menstruators’ as is demonstrated in a UK National Health Service Trust guide to ‘Gender Inclusive Language In Perinatal Services’ [7]. In this paper, we use the term menstruator, however quotes from interviews and the literature still use gendered binary terms ’women’ and ’girls’. Background Poor access to menstrual health—comprising education, materials, water, sanitation and hygiene (WaSH) facilities, disposal methods, healthcare, a supportive environment, and the choice to participate in daily activities—is a global issue [9]. Menstruation is documented internationally as a stigmatised and taboo topic meaning conversations around the subject are often either wrongly informed, minimal or non-existent [6]. In the absence of a clear and open debate, WaSH services may not consider menstrual health, and fail to deliver menstruator-friendly, culturally appropriate WaSH facilities [24]. A lack of or inappropriate solutions may cause shame, stress, exhaustion, fear, embarrassment, stigma, loss of dignity, and Gender-Based Violence (GBV); since Menstrual Hygiene Management (MHM) requires privacy, menstruators often choose to use WaSH facilities at night, leaving them susceptible to attack and sexual assault [10]. These issues are exacerbated in humanitarian settings due to overcrowding, decreased lack of facilities and materials, and safety issues [18]. The UNHCR [28] estimates that 110 million people (1.4% of the global population) are currently forcibly displaced – of these 29 million are menstruators. Therefore, MHM in humanitarian settings is a significant challenge that needs to be addressed urgently. Current menstrual health guidance from NGOs advocates for the consultation of menstruators on their needs before implementing a menstrual health project [18, 23]. Additionally, in humanitarianism, general opinion is Page 2 of 12 that humanitarian action is ‘best developed with and for affected people’ [33], p. 13). By shaping projects around local sociocultural, economic and political situations, listening to people’s (...truncated)