A voice in the choice: Adolescent girls' participation in menstrual material decisions and its association with reduced unmet needs — evidence from the AMEHC study

Abstract

Background: Adolescent schoolgirls in low-resource settings face extensive structural and social barriers to managing menstruation with dignity. While economic constraints are frequently studied, the protective value of adolescent individual voice and household-level purchasing autonomy remains under-researched. This study evaluated the cross-sectional association between adolescent girls’ participation in menstrual material purchasing choices and their ability to meet comprehensive menstrual practice needs in the Khulna district of Bangladesh.

Methods: A complete-case analysis was conducted using cross-sectional data collected in 2024 for the Adolescent Menstrual Experiences and Health Cohort (AMEHC) study. From a baseline enrollment of 2,015 Class 6 schoolgirls, the final analytical sample was restricted to n = 1,464 post-menarche students who possessed non-missing covariate responses. This stabilization followed the sequential exclusion of 385 participants who were pre-menarche at Wave 1, 95 with missing data on purchasing decisions, 70 with incomplete responses on the outcome scale, and 1 case with missing social support data. Menstrual practice needs were measured using the validated 18-item Menstrual Practice Needs Scale–Short Form (MPNS-SF). Primary exposure agency was operationalized as a binary indicator tracking independent or joint adolescent participation in purchasing choices. To account for institutional school-level clustering across 101 physical school sites, multi-level mixed-effects logistic regression models were developed to estimate adjusted odds ratios (aOR) at a 95% confidence interval (CI).

Results: The mean age of the post-menarche sample was 12.4 years, and 56.4% of the cohort actively participated in material purchasing decisions. After adjusting simultaneously for age, geographic setting, household wealth quintiles, parental baseline gender norms, and individual beliefs, active adolescent purchasing participation was significantly associated with a 31% lower odds of experiencing comprehensive unmet menstrual needs (aOR = 0.69; 95% CI: [0.52, 0.93]; p = 0.014). Strong negative statistical associations with the outcome were also observed for the background adjustment covariates of higher maternal social support (aOR = 0.17; 95% CI: [0.11, 0.26]; p < 0.001) and equitable personal gender norms (aOR = 0.56; 95% CI: [0.39, 0.80]; p = 0.002). Household wealth and geographic region setting did not maintain independent statistical associations within the fully adjusted multi-level specification.

Conclusions: Individual purchasing agency and supportive social networks demonstrate strong negative statistical correlations with unmet menstrual needs. Because this model adjusted for psychosocial traits and decision-making access simultaneously, the null findings for household wealth may reflect statistical mediation paths rather than a true absence of economic influence. Public health interventions should move beyond basic material aid to focus on increasing supportive household communication with the adolescent girls, shifting restrictive personal gender beliefs, and expanding girls' active participation in health-related material choices.