Abstract
Objectives: This cross-sectional retrospective survey study modeled on previous research explored the prevalence of period poverty in 1 urban setting to inform future targeted interventions toward improving menstrual equity.
Methods: An 8-item questionnaire was developed by a menstrual health equity work group led by the Allentown Health Bureau, Pennsylvania. Data collection occurred for 1.5 years, using an anonymous online survey tool and convenience sampling. Study participants were recruited with an informational flier (with QR code and web address pointing to the questionnaire) posted in various public locations.
Results: A total of 353 people who menstruate, aged 13 to 54, representing 5 of Allentown’s 7 ZIP code regions responded. The majority were impacted by period poverty, either by missing a life event (77.9%) or engaging in an at-risk menstrual hygiene behavior (79.0%). Most (91.5%) had been educated in menstrual health. Doctor’s offices (40.3%) and social media (27.8%) were the most frequently cited sources for learning about the survey. ZIP codes were significantly associated with engaging in at-risk behaviors (P < .001), missing a life event (P < .001), no menstrual health education (P = .03), and preference for period underwear (P = .04). Age was significantly associated with preferring pads (P = .007) and tampons (P = .03).
Conclusions: Period poverty was found to impact a substantial number of people in Allentown, Pennsylvania. Interventions will need to be tailored to ZIP code and age-group. Future study should aim for a larger sample size and additional questions, about menstrual education.
- Community-Based Research
- Health Disparities
- Health Equity
- Menstrual Hygiene Products
- Pennsylvania
- Poverty
- Public Health
- Reproductive Health
- Social Justice
- Women's Health
Introduction
Period poverty impacts individuals who menstruate worldwide.1,2 It is defined as lack of access to menstrual hygiene products, health education, or sanitation facilities. Menstrual equity, on the other hand, focuses on ensuring that all individuals have what they need for menstrual hygiene management,1,3 to avoid monthly disruptions in life events, such as missing school or work. While menstrual equity is an achievable goal, its solution remains elusive as period poverty is influenced by one’s socioeconomic status, cultural context,1 menstrual knowledge,4 and geographic location.2
In the United States, the COVID-19 pandemic brought this already-growing public health concern5 into greater focus, as the economic climate strained household budgets and further reduced period product access for all menstruators.6 An estimated 59% of US individuals aged 18 to 49 who menstruate experienced period poverty in 2021, up from 53% just 3 years earlier.5 Recent data show that being Hispanic and having lower education levels puts individuals at risk for period poverty.6,7 Transgender and nonbinary individuals who menstruate may face additional barriers to accessing period products and menstrual health education, although little data exists about this population’s experiences.8
Globally, lack of access to menstrual products raises a host of biopsychosocial concerns, including physical illnesses, such as urinary tract infections and other reproductive health issues3,7,9; stigmatization and shame10–12; missed life events7,9,13,14; and engagement in at-risk health behaviors, such as relying on makeshift alternatives,15 extending product usage to manage menstruation, or resorting to transactional sexual encounters to obtain needed period products.16,17 Thus, protecting menstrual health as a “fifth vital sign”4 requires a multi-perspective approach.
Interventions to address period poverty include distribution of free menstrual hygiene supplies,14,18 public health education initiatives,18 and policy change.12,18 For example, in the United States, a 2024 pre/post survey study of menstruators who received free menstrual hygiene products from so-called “period supply banks” found that nearly 50% of participants no longer had to choose between buying menstrual hygiene products and paying for other basic needs as a result of the distribution.14 The study also found that number of missed life events (eg, school, work, appointments) dropped from an average 7.8 days per year at baseline to 1.2 days per year after connecting participants with free period products.14 From a policy perspective, 15 states took action on 58 pieces of legislation related to menstrual health in 2024 alone, according to a database maintained by Women’s Voices for the Earth, a women’s health advocacy organization.19 A similar policy and legislation tracking list maintained by Aunt Flow, another nonprofit organization lists 43 pieces of legislation across the United States that require free access to period products.20 However, many states still levy taxes on menstrual products,21 and government assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP), do not allow benefits to be used for hygiene products.22
The current study explores the impact of period poverty in the third-largest city in Pennsylvania23 to inform future interventions to improve menstrual equity in the region. Through a collaboration with a local community health collaborative, a primary care research team analyzed survey data to determine whether city residents experienced disruptions in life events or engaged in at-risk menstrual hygiene behaviors as a result of not being able to afford period products. Researchers also explored whether differences existed in period product preferences and menstrual health education status by age or ZIP code of residence. The purpose of this study is twofold: 1) to devise a targeted, relevant, and appropriate intervention to mitigate period poverty among the study population, and 2) to add to the extant literature on this complex, ever-growing public health issue. Before this study, no known data existed that was specific to this region.
Methods
Setting, Population, and Data Collection
This retrospective, cross-sectional, explanatory, survey-based study was designed to provide insight about the impact of period poverty in Allentown, Pennsylvania. The population of interest was menstruators aged 13 to 54 years old residing in any of the city’s 7 ZIP code tabulation areas (ZCTAs). Data collection occurred from August 1, 2022, through February 4, 2024, using convenience sampling with an online, 8-item anonymous questionnaire. Currently, there are no data estimates on the number of people who menstruate in Allentown, hence study size was determined by convenience sampling in the given timeline. The duration of data collection determined the study size. Study participants were recruited with an informational flier posted in various public locations (eg, public library, medical offices, food bank, social media sites, educational institutions). The flier had a QR code for participants to scan and also a web address for the survey. Participation required internet access and the ability to read the questionnaire items in either English or Spanish. Participants were excluded if they failed to provide a ZIP code or responded with a ZIP code outside of Allentown.
Purpose and Outcomes of Interest
Period poverty was operationalized as missing life events (ie, work, school, social activities, or other event) or engaging in at-risk (for period poverty) menstrual hygiene behaviors as a result of not having enough money to purchase period products. At-risk behaviors included engaging in at least one of the following: (1) used other products such as fabric or toilet article, (2) got products from friends, coworkers, or strangers, (3) left a period product in too long, or (4) going without any products. Secondary outcomes included preferred period product type (pads, tampons, period cup, period underwear, reusable cloth pads, other); menstrual education status (yes/no response to “Has anyone ever talked to you about your period?”); and where the participant learned about the survey. Respondent demographic data (age-group, ZIP code) also were collected.
Patient and Public Involvement
The research questions and outcome measures were developed by a community health collaborative comprising individuals from 2 local health networks, a public school system, an LGBTQ+ community center, a sexual health advocacy organization, the city library, and the city health bureau. The Allentown Health Bureau convened this group in 2022 to explore developing a pilot program to address menstrual inequity/period poverty in Allentown. The research question was informed by anecdotal evidence from physicians, public health nurses and school nurses concerned about patients experiencing period poverty.
Data Analysis
Survey responses were shared with a primary care research team (2 clinical researchers, 2 graduate students, a research associate, and a biostatistician) for analysis and interpretation. Descriptive statistics were used to present survey data. Categorical variables were presented as frequency and percentage, and continuous variables were represented with the mean and standard deviation or median and interquartile ranges, depending on normality of the distribution. A composite binary variable was created for 2 survey questions (at-risk behaviors and missed life events) for which respondents were able to select more than 1 response. For these composite variables, if a respondent selected at least 1 response, they were considered to have the respective outcome. Few responses were missing data and were excluded in the respective bivariate analyses.
Bivariate analyses using the χ2 or Fisher exact tests were used to assess the associations between survey responses and ZIP code. The same methodology was used to assess the associations between menstrual education and period product preference and age. A Monte Carlo simulation was used when a Fisher exact test could not be run. To further examine the relationship between ZIP code and the primary outcomes of engaging in at least 1 at-risk behavior and missing at least 1 event when menstruating, crude and adjusted penalized logistic regression models were used, controlling for age, menstrual education status, and period product preference. Of the model covariates the following reference groups were assigned: ZIP code (18104), age (25 to 34), menstrual education (yes, prior education), period product preference (no preference). Assumptions of the models’ including multicollinearity were assessed and met. The Hosmer-Lemeshow goodness-of-fit statistic indicated good model fit (P > . 05).
This study underwent ethics review by the institutional review board of the health network that employs the primary care research team. The project met criteria for approval per US Department of Health and Human Services regulation 45 CFR 46.111 and was granted a waiver of consent because it was deemed to entail minimal risk to participants.
Results
Of the 424 survey responses received, 353 met inclusion criteria (Figure 1). Five of the city’s ZIP codes were represented in the study data, with nearly half of respondents (170/353, 48.1%) residing in ZCTA 18102. Just over one-third (122/353, 34.7%) were aged 25 to 34, and the majority (321/353, 91.5%) had been educated in menstrual health. The largest proportion heard about the survey at a doctor’s office (142/353, 40.3%) with many others learning about it on social media (98/353, 27.8%). See Table 1 for a breakdown of survey responses by ZIP code.
Sample size flowchart.
Survey Responses Stratified by ZIP Code (n = 353)
Primary Objective: Period Poverty Indicators
The majority of respondents overall indicated they had experienced period poverty, either by engaging in at least 1 at-risk menstrual hygiene behavior (279/353, 79.0%) or missing at least 1 life event (275/353, 77.9%) due to not having period products when menstruating. For both of these composite variables, ZIP code of residence was significantly associated with period poverty (P < .001) (Table 1) 3 hygiene behavior responses were significantly associated with ZIP code (going without products, P = .007; getting products from other people; P = .004, and having access to products; P = . 007). (Figure 2) Missing work (P = .01) and other life events (P = .01) also were significantly associated with where the respondent lived (Figure 3).
At-risk hygiene behavior responses by ZIP code (n = 353).
Missed life event responses by ZIP code (n = 353).
In adjusted logistic regression controlling for age, period education, and menstrual product preference, ZIP code remained a statistically significant predictor for engaging in at least 1 at-risk menstrual hygiene behavior (P < .001) and for missing at least 1 life event (P = .001). As compared with ZCTA 18104, the odds of engaging in an at-risk menstrual hygiene behavior were as follows: 18102, aOR 2.4 (95% CI, 1.2 to 4.7); 18103, aOR 2.8 (95% CI, 1.3 to 6.3); 18109, aOR 43.4 (95% CI, 2.7 to 701.1), controlling for age, period education, and menstrual product preference. (Figure 4).
Forest plot of adjusted odds ratios from penalized logistic regression models for engaging in at-risk hygiene behaviors by ZIP code, controlling for age, period education, and product preference (n = 353).
All the ZIP codes had significantly higher odds of missing an event than participants in 18104. As compared with ZCTA 18104, the odds of missing an event due to not having period products while menstruating were 18101, aOR 8.0 (95% CI, 1.3 to 48.1); 18102, aOR 3.1 (95% CI, 1.6-6.1); 18103, aOR 2.8 (95% CI, 1.3 to 6.2); 18109, aOR 6.8 (95% CI, 1.9 to 24.0), controlling for age, period education, and menstrual product preference. (Figure 5).
Forest plot of adjusted odds ratios from penalized logistic regression models for missing life events by ZIP code, controlling for age, period education, and product preference (n = 353).
Secondary Objective: Product Preference and Period Knowledge
ZIP code also was significantly associated with where participants heard about the survey (P = .009) and their menstrual education status (P = .03). Larger proportions of residents in 18101 (8/17, 47.1%) and 18104 (30/58, 51.7%) learned about the survey via social media, whereas respondents in all other ZIP codes heard about the survey at their doctor’s office/clinic. While the majority of respondents overall (321/353, 91.5%) indicated they had menstrual education, there was a significantly larger proportion of individuals who had not been educated about menstruation in ZIP codes 18101 (11.8%), 18102 (13.0%), and 18109 (8.8%) than in the other ZCTAs. (Table 1).
As for period products, respondents across ZIP codes preferred pads (301/353, 85.3%). Tampons were the second most preferred overall (146/353, 41.4%). However, in 18101, a significantly larger proportion of respondents (6/18, 33.3%) preferred period underwear than in other ZIP codes.
Analysis of the overall sample revealed a significant association between age and preference for pads and tampons. As age increased, the proportion of respondents who preferred pads decreased significantly (P = .007). For tampons, the preference among those in the 18 to 24 age-group (30/59, 50.9%) was significantly higher (P = .03) than those under age 18 (8/40, 20%) and ages 45 to 54 (13/36, 69.4%). (Table 2).
Menstrual Education and Product Preference by Age
Discussion
This study revealed that where participants live within the city limits of Allentown, Pennsylvania, served as a predictor for whether and how they experienced period poverty. The ZIP codes represented in this study have diverse demographic profiles.24 (Table 3).
Demographic Characteristics of Allentown and 5 ZIP Codes Represented in Survey Data
The study team had hypothesized that the 18102 ZCTA would be most impacted. However, findings indicated that period poverty is more widespread than expected, manifesting as at-risk menstrual hygiene behaviors in some areas, and as missed life events in others.
While many previous studies on the impact of period poverty have utilized qualitative methods, some emergent themes—such as affordability of period products,25 use of alternative materials,25 and extended wear of products25 — aligned with this study’s operationalization of period poverty. Most studies, like this one, had narrowly defined populations. For example, a survey of 119 students in St. Louis, Missouri, showed 64.4% experienced period product insecurity and 33.6% missed school due to a lack of period products.13 Another St. Louis-based study of 184 low-income women found that 64% could not afford menstrual products and reported using alternative items to manage their hygiene needs.15 Two different studies of college-aged menstruators (n = 471 and n = 106) showed a much lower proportions (14.2% and 17.1%, respectively) who experienced period poverty.11,26 However among those who did, the percentages of those who engaged in at-risk menstrual hygiene behaviors, such as getting products from others (72.8%), using alternative products (52.6%), and wearing products longer than indicated (48.3%)11 were similar to the current study results.
Study Strengths and Limitations
This study focused in on Allentown, Pennsylvania, using ZCTAs, to define respondent context, using easily accessible demographic data from the US Census Bureau. However, the convenience sampling method’s inherent flaw is that it is unlikely to obtain an equal distribution of participants from each data subset. To account for this, statistical tests designed to analyze uneven and smaller data sets, such as the Monte Carlo simulation and penalized regression, were utilized as needed. Similarly, smaller sample sizes impacted odds ratios and confidence intervals in the logistic regression analyses, so alternative statistical methods (Firth’s correction) were used to obtain more precise estimates. Future studies would benefit from larger datasets. In addition, 3 of the City of Allentown zip codes (18103, 18104 and 18109) are shared with surrounding municipalities. This must be acknowledged while interpreting our results. To determine whether survey respondents reside in the city, data must be collected by address, census tract or ward in future projects. Another potential limitation is that the questionnaire did not clarify from whom menstrual education was obtained (eg, parent, teacher, doctor). Future studies should specify which resources menstruators utilized to assess the validity of this response. Any self-report data collection method, such as a questionnaire, has limitations related to recall bias, reliability, and validity. The small sample size, small number of survey questions, and individualized and variable experiences with menstruation all pose limitations to study outcomes. Online survey method has its own limiting factors for recruitment, including the assumption that participants have access to technology and internet connectivity as well as the ability to read and understand English language independently, all which may be reduced given the demographics of this region. That said, this is the only study to date of menstruators in this city, so any information gathered will serve to inform a targeted intervention to alleviate period poverty.
Implications for Practice
This study exemplifies the benefits of collaboration between primary care research teams and community organizations to explore the impact of a public health concern. The purpose of this study and the data collected provide insight into period poverty in Allentown, Pennsylvania, and will inform a future intervention in this area. However, this study serves as a potential model for community-based research to advance menstrual equity efforts in other areas. It also brings attention to topics that clinicians may be able to address with patients about menstrual health behaviors and needs, such as period product preferences and access to supplies.
Conclusion
This study revealed that the impact of period poverty in Allentown, Pennsylvania, is greater than perceived by researchers, and that the issue manifests differently in various demographic areas. Lack of menstrual education does not seem to be the driver of period poverty, as overall, most menstruators have received some information about having a period. Interventions will need to vary by location and age-group, as menstruators prefer different products and resort to different behaviors as a result of not having appropriate products. Initiating menstrual equity efforts from health care centers and through social media campaigns will likely reach the largest proportion of those impacted in this region.
Acknowledgments
The authors thank the Allentown PA Menstrual Equity work group, which included representatives from Allentown Health Bureau, Lehigh Valley Health Network (LVHN), Allentown School District, Allentown Public Library, Bradbury-Sullivan LGBT Community Center, St. Luke’s Health Network, and Planned Parenthood. We acknowledge and are grateful for University of South Florida Morsani College of Medicine medical students, Sejal Jain, Samantha Finkelstein, Fawaz Hussain, Clara Freedman, Berwin Yuan, and Brett O’Donnell, who contributed to the initiation of this project, helped with question creation, questionnaire distribution, and assisted with menstrual equity collaborative work. Special thanks to Sandra Boakye, Founder/Executive Director of Inspire Her Ghana who assisted with reviewing the final draft of this manuscript; and Dr. Autumn Kieber-Emmons, vice chair of research, LVHN Department of Family Medicine, who served in a consultative role.
The authors would like to specially thank Erin Barron, Clinical Services Manager, Allentown Health Bureau, who was instrumental in the survey development, implementation, and retrieving data from the Survey Monkey database for analysis.
Notes
This article was externally peer reviewed.
Funding: This study was not funded.
Conflict of interest: Ashwini Kamath Mulki received $21 in food and beverage from the former Valeant Pharmaceuticals North America LLC (now Bausch Health Companies Inc.) in 2017 during a Nexplanon implant training session. Rosalie Mattiola, Susan E. Hansen, Shae Duka, Amanda Hoyer, Belle P. Marks, Crystal Perez, and Nicole Burgess have no conflicts to disclose.
- Received for publication March 4, 2025.
- Revision received May 5, 2025.
- Accepted for publication May 19, 2025.
