CINXE.COM

<!DOCTYPE html> <html xmlns="http://www.w3.org/1999/xhtml" xmlns:dc="http://purl.org/dc/terms/" xmlns:doi="http://dx.doi.org/" lang="en" xml:lang="en" itemscope itemtype="http://schema.org/Article" class="no-js"> <head prefix="og: http://ogp.me/ns#"> <link rel="stylesheet" href="/resource/css/screen.css?112d78c04dc25a6fb55b68d577e0729a"/>   <link rel="stylesheet" type="text/css" href="https://fonts.googleapis.com/css?family=Open+Sans:400,400i,600"> <link media="print" rel="stylesheet" type="text/css" href="/resource/css/print.css"/> <script type="text/javascript"> var siteUrlPrefix = "/plosone/"; </script> <script src="/resource/js/vendor/modernizr-v2.7.1.js" type="text/javascript"></script> <script src="/resource/js/vendor/detectizr.min.js" type="text/javascript"></script> <link rel="shortcut icon" href="/resource/img/favicon.ico" type="image/x-icon"/> <meta http-equiv="Content-Type" content="text/html; charset=utf-8"/> <link rel="canonical" href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0303378" /> <meta name="description" content="Background Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages—such as homelessness or drug injection practices–often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel ‘MH WASH Domain Scale-12’ among people who menstruate and who inject drugs in the Tijuana–San Diego region and identified correlates of MH access using this scale. Methods We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0–12 points and higher scores indicating better MH access. We assessed the scale’s reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020–2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. Results Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our ‘MH WASH Domain Scale-12’ was reliable (Cronbach’s alpha = 0.81, McDonald’s Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing ‘WASH availability’ and Factor-2 contained items related to ‘WASH security’—encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. Conclusion We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region." /> <meta name="citation_abstract" content="Background Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages—such as homelessness or drug injection practices–often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel ‘MH WASH Domain Scale-12’ among people who menstruate and who inject drugs in the Tijuana–San Diego region and identified correlates of MH access using this scale. Methods We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0–12 points and higher scores indicating better MH access. We assessed the scale’s reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020–2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. Results Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our ‘MH WASH Domain Scale-12’ was reliable (Cronbach’s alpha = 0.81, McDonald’s Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing ‘WASH availability’ and Factor-2 contained items related to ‘WASH security’—encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. Conclusion We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region."> <meta name="keywords" content="Sanitation,Housing,Sex work,Soaps,Urban areas,Hygiene,Measurement,Schools" /> <meta name="citation_doi" content="10.1371/journal.pone.0303378"/> <meta name="citation_author" content="Alhelí Calderón-Villarreal"/> <meta name="citation_author_institution" content="Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego (UCSD), San Diego, California, United States of America"/> <meta name="citation_author_institution" content="School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America"/> <meta name="citation_author" content="Lourdes Johanna Avelar Portillo"/> <meta name="citation_author_institution" content="Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America"/> <meta name="citation_author_institution" content="Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, California, United States of America"/> <meta name="citation_author" content="Daniela Abramovitz"/> <meta name="citation_author_institution" content="Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America"/> <meta name="citation_author" content="Shira Goldenberg"/> <meta name="citation_author_institution" content="School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America"/> <meta name="citation_author" content="Shawn Flanigan"/> <meta name="citation_author_institution" content="School of Public Affairs, SDSU, San, Diego, California, United States of America"/> <meta name="citation_author" content="Penelope J. E. Quintana"/> <meta name="citation_author_institution" content="School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America"/> <meta name="citation_author" content="Alicia Harvey-Vera"/> <meta name="citation_author_institution" content="Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America"/> <meta name="citation_author_institution" content="Universidad de Xochicalco, Tijuana, Baja California, Mexico"/> <meta name="citation_author" content="Carlos F. Vera"/> <meta name="citation_author_institution" content="Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, California, United States of America"/> <meta name="citation_author" content="Gudelia Rangel"/> <meta name="citation_author_institution" content="El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico"/> <meta name="citation_author_institution" content="Border Health Commission, Tijuana, Baja California, Mexico"/> <meta name="citation_author" content="Steffanie A. Strathdee"/> <meta name="citation_author_institution" content="Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America"/> <meta name="citation_author" content="Georgia L. Kayser"/> <meta name="citation_author_institution" content="Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America"/> <meta name="citation_title" content="A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs"/> <meta itemprop="name" content="A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs"/> <meta name="citation_journal_title" content="PLOS ONE"/> <meta name="citation_journal_abbrev" content="PLOS ONE"/> <meta name="citation_date" content="May 10, 2024"/> <meta name="citation_firstpage" content="e0303378"/> <meta name="citation_issue" content="5"/> <meta name="citation_volume" content="19"/> <meta name="citation_issn" content="1932-6203"/> <meta name="citation_publisher" content="Public Library of Science"/> <meta name="citation_pdf_url" content="https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0303378&type=printable"> <meta name="citation_article_type" content="Research Article"> <meta name="dc.identifier" content="10.1371/journal.pone.0303378" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:site" content="plosone"/> <meta name="twitter:title" content="A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs" /> <meta property="twitter:description" content="Background Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages—such as homelessness or drug injection practices–often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel ‘MH WASH Domain Scale-12’ among people who menstruate and who inject drugs in the Tijuana–San Diego region and identified correlates of MH access using this scale. Methods We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0–12 points and higher scores indicating better MH access. We assessed the scale’s reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020–2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. Results Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our ‘MH WASH Domain Scale-12’ was reliable (Cronbach’s alpha = 0.81, McDonald’s Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing ‘WASH availability’ and Factor-2 contained items related to ‘WASH security’—encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. Conclusion We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region." /> <meta property="twitter:image" content="https://journals.plos.org/plosone/article/figure/image?id=10.1371/journal.pone.0303378.g002&size=inline" /> <meta property="og:type" content="article" /> <meta property="og:url" content="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0303378"/> <meta property="og:title" content="A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs"/> <meta property="og:description" content="Background Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages—such as homelessness or drug injection practices–often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel ‘MH WASH Domain Scale-12’ among people who menstruate and who inject drugs in the Tijuana–San Diego region and identified correlates of MH access using this scale. Methods We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0–12 points and higher scores indicating better MH access. We assessed the scale’s reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020–2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates. Results Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our ‘MH WASH Domain Scale-12’ was reliable (Cronbach’s alpha = 0.81, McDonald’s Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing ‘WASH availability’ and Factor-2 contained items related to ‘WASH security’—encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing. Conclusion We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region."/> <meta property="og:image" content="https://journals.plos.org/plosone/article/figure/image?id=10.1371/journal.pone.0303378.g002&size=inline"/> <meta name="citation_reference" content="citation_title=Menstrual health: a definition for policy, practice, and research.;citation_author=J Hennegan;citation_author=IT Winkler;citation_author=C Bobel;citation_author=D Keiser;citation_author=J Hampton;citation_author=G Larsson;citation_journal_title=Sex Reprod Health Matters;citation_volume=29;citation_number=29;citation_first_page=1911618;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=Inclusivity starts with language;citation_author=R Kamau;citation_author=JS Martin;citation_author=A Calderón-Villarreal;citation_author=C Jacobs;citation_journal_title=The Lancet;citation_volume=399;citation_number=399;citation_first_page=434;citation_last_page=435;citation_publication_date=2022;"/> <meta name="citation_reference" content="citation_title=Menstrual Hygiene Needs Among Women Undergoing Substance Use Disorder Treatment;citation_author=V Keiser;citation_author=AB Parlier-Ahmad;citation_author=AS Kuhlmann;citation_author=CE Martin;citation_journal_title=Obstet Gynecol;citation_volume=136;citation_number=136;citation_first_page=768;citation_last_page=770;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=An Ethnographic Assessment of COVID-19‒Related Changes to the Risk Environment for People Who Use Drugs in Tijuana, Mexico.;citation_author=J Friedman;citation_author=A Calderón-Villarreal;citation_author=RC Adame;citation_author=D Abramovitz;citation_author=C Rafful;citation_author=G Rangel;citation_journal_title=Am J Public Health.;citation_volume=112;citation_number=112;citation_first_page=S199;citation_last_page=S205;citation_publication_date=2022;"/> <meta name="citation_reference" content="citation_title=Deported, homeless, and into the canal: Environmental structural violence in the binational Tijuana River.;citation_author=A Calderón-Villarreal;citation_author=B Terry;citation_author=J Friedman;citation_author=SA González-Olachea;citation_author=A Chavez;citation_author=M Díaz López;citation_journal_title=Soc Sci Med;citation_volume=305;citation_number=305;citation_first_page=115044;citation_publication_date=2022;"/> <meta name="citation_reference" content="citation_title=Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California.;citation_author=LJ Avelar Portillo;citation_author=GL Kayser;citation_author=C Ko;citation_author=A Vasquez;citation_author=J Gonzalez;citation_author=DJ Avelar;citation_journal_title=Int J Equity Health;citation_volume=22;citation_number=22;citation_first_page=108;citation_publication_date=2023;"/> <meta name="citation_reference" content="citation_title=‘You feel how you look’: Exploring the impacts of unmet water, sanitation, and hygiene needs among rural people experiencing homelessness and their intersection with drug use.;citation_author=AM Ballard;citation_author=HLF Cooper;citation_author=AM Young;citation_author=BA Caruso;citation_journal_title=PLOS Water.;citation_volume=1;citation_number=1;citation_first_page=e0000019;citation_publication_date=2022;"/> <meta name="citation_reference" content="citation_title=Water, sanitation and hygiene: measuring gender equality and empowerment;citation_author=GL Kayser;citation_author=N Rao;citation_author=R Jose;citation_author=A Raj;citation_journal_title=Bull World Health Organ;citation_volume=97;citation_number=97;citation_first_page=432;citation_last_page=440;citation_publication_date=2019;"/> <meta name="citation_reference" content="citation_title=Water, sanitation and hygiene at sex work venues to support menstrual needs.;citation_author=PA Phillips-Howard;citation_author=E Osire;citation_author=C Akinyi;citation_author=G Zulaika;citation_author=FO Otieno;citation_author=SD Mehta;citation_journal_title=Front Public Health;citation_first_page=12;citation_publication_date=2024;"/> <meta name="citation_reference" content="citation_title=Measurement in the study of menstrual health and hygiene: A systematic review and audit.;citation_author=J Hennegan;citation_author=DJ Brooks;citation_author=KJ Schwab;citation_author=GJ Melendez-Torres;citation_journal_title=PLOS ONE.;citation_volume=15;citation_number=15;citation_first_page=e0232935;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=National Monitoring for Menstrual Health and Hygiene: Is the Type of Menstrual Material Used Indicative of Needs Across 10 Countries?;citation_author=AD Smith;citation_author=A Muli;citation_author=KJ Schwab;citation_author=J Hennegan;citation_journal_title=Int J Environ Res Public Health;citation_volume=17;citation_number=17;citation_first_page=2633;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=Taxing women’s bodies: the state of menstrual product taxes in the Americas;citation_author=A. Calderón-Villarreal;citation_journal_title=Lancet Reg Health—Am;citation_volume=29;citation_number=29;citation_first_page=100637;citation_publication_date=2024;"/> <meta name="citation_reference" content="citation_title=Joint Monitoring Program (JMP).;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=Measuring menstrual hygiene experience: development and validation of the Menstrual Practice Needs Scale (MPNS-36) in Soroti, Uganda.;citation_author=J Hennegan;citation_author=A Nansubuga;citation_author=C Smith;citation_author=M Redshaw;citation_author=A Akullo;citation_author=KJ Schwab;citation_journal_title=BMJ Open.;citation_volume=10;citation_number=10;citation_first_page=e034461;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=The Menstrual Practices Questionnaire (MPQ): development, elaboration, and implications for future research.;citation_author=J Hennegan;citation_author=A Nansubuga;citation_author=A Akullo;citation_author=C Smith;citation_author=KJ Schwab;citation_journal_title=Glob Health Action.;citation_volume=13;citation_number=13;citation_first_page=1829402;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=Indicators for National and Global Monitoring of Girls’ Menstrual Health and Hygiene: Development of a Priority Shortlist.;citation_author=J Hennegan;citation_author=BA Caruso;citation_author=G Zulaika;citation_author=B Torondel;citation_author=J Haver;citation_author=PA Phillips-Howard;citation_journal_title=J Adolesc Health;citation_volume=73;citation_number=73;citation_first_page=992;citation_last_page=1001;citation_publication_date=2023;"/> <meta name="citation_reference" content="citation_title=Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in the San Diego-Tijuana border region.;citation_author=SA Strathdee;citation_author=D Abramovitz;citation_author=A Harvey-Vera;citation_author=CF Vera;citation_author=G Rangel;citation_author=I Artamonova;citation_journal_title=PLOS ONE.;citation_volume=16;citation_number=16;citation_first_page=e0260286;citation_publication_date=2021;"/> <meta name="citation_reference" content="US Department of Housing and Urban Development. The 2020 Annual Homeless Assessment Report (AHAR) to Congress. 2021. Available: https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf ."/> <meta name="citation_reference" content="citation_title=HMIS Related HUD Definitions;citation_journal_title=HMIS Related HUD Definitions;citation_publication_date=2014;"/> <meta name="citation_reference" content="DeVellis RF. Scale Development: Theory and Applications. Los Angeles; 2016."/> <meta name="citation_reference" content="citation_title=Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer.;citation_author=GO Boateng;citation_author=TB Neilands;citation_author=EA Frongillo;citation_author=HR Melgar-Quiñonez;citation_author=SL Young;citation_journal_title=Front Public Health;citation_volume=6;citation_number=6;citation_publication_date=2018;"/> <meta name="citation_reference" content="citation_title=Construct Validity in Health Behavior Research: Interpreting Latent Variable Models Involving Self-Report and Objective Measures.;citation_author=RF Palmer;citation_author=JW Graham;citation_author=B Taylor;citation_author=J Tatterson;citation_journal_title=J Behav Med.;citation_volume=25;citation_number=25;citation_first_page=525;citation_last_page=550;citation_publication_date=2002;"/> <meta name="citation_reference" content="citation_title=Constructing validity: Basic issues in objective scale development;citation_author=LA Clark;citation_author=D Watson;citation_journal_title=Psychol Assess;citation_volume=7;citation_number=7;citation_first_page=309;citation_last_page=319;citation_publication_date=1995;"/> <meta name="citation_reference" content="citation_title=Monitoring WASH in Health Care Facilities. Final Core Indicators and Questions;citation_journal_title=Monitoring WASH in Health Care Facilities. Final Core Indicators and Questions;citation_publication_date=2016;"/> <meta name="citation_reference" content="citation_title=Compliance on existing WASH facilities in community clinics of Bangladesh: A comparative study.;citation_author=N Akter;citation_author=B Banu;citation_author=SM Hossain;citation_author=SH Shakib;citation_author=ASN Awal;citation_journal_title=Heliyon.;citation_volume=7;citation_number=7;citation_first_page=e07549;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=Water, sanitation and hygiene for homeless people.;citation_author=SMN Uddin;citation_author=V Walters;citation_author=JC Gaillard;citation_author=SM Hridi;citation_author=A McSherry;citation_journal_title=J Water Health;citation_volume=14;citation_number=14;citation_first_page=47;citation_last_page=51;citation_publication_date=2016;"/> <meta name="citation_reference" content="citation_title=What are the psychometric properties of a menstrual hygiene management scale: a community-based cross-sectional study.;citation_author=A Ramaiya;citation_author=S Sood;citation_journal_title=BMC Public Health.;citation_volume=20;citation_number=20;citation_first_page=525;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=A Review of Measures and Indicators for Gender in WASH;citation_author=BA Caruso;citation_author=A Salinger;citation_author=M Patrick;citation_author=A Conrad;citation_author=S Sinharoy;citation_journal_title=A Review of Measures and Indicators for Gender in WASH;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region.;citation_author=LJ Avelar Portillo;citation_author=A Calderón-Villarreal;citation_author=D Abramovitz;citation_author=A Harvey-Vera;citation_author=S Cassels;citation_author=CF Vera;citation_journal_title=BMC Public Health;citation_volume=24;citation_number=24;citation_first_page=19;citation_publication_date=2024;"/> <meta name="citation_reference" content="citation_title=A Conceptual Framework to Inform National and Global Monitoring of Gender Equality in WASH;citation_author=BA Caruso;citation_author=A Conrad;citation_author=A Salinger;citation_author=M Patrick;citation_author=A Youm;citation_author=S Sinharoy;citation_journal_title=A Conceptual Framework to Inform National and Global Monitoring of Gender Equality in WASH;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=The water, sanitation and hygiene gender equality measure (WASH-GEM): Conceptual foundations and domains of change.;citation_author=N Carrard;citation_author=J MacArthur;citation_author=C Leahy;citation_author=S Soeters;citation_author=J Willetts;citation_journal_title=Womens Stud Int Forum;citation_volume=91;citation_number=91;citation_first_page=102563;citation_publication_date=2022;"/> <meta name="citation_reference" content="citation_title=Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020–2021: a cross-sectional study.;citation_author=A Calderón-Villarreal;citation_author=LJ Avelar Portillo;citation_author=D Abramovitz;citation_author=S Goldenberg;citation_author=S Flanigan;citation_author=PJE Quintana;citation_journal_title=Int J Equity Health.;citation_volume=23;citation_number=23;citation_first_page=79;citation_publication_date=2024;"/> <meta name="citation_reference" content="citation_title=Seeking menstrual products: a qualitative exploration of the unmet menstrual needs of individuals experiencing homelessness in New York City.;citation_author=C Gruer;citation_author=K Hopper;citation_author=RC Smith;citation_author=E Kelly;citation_author=A Maroko;citation_author=M Sommer;citation_journal_title=Reprod Health;citation_volume=18;citation_number=18;citation_first_page=77;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York.;citation_author=AR Maroko;citation_author=K Hopper;citation_author=C Gruer;citation_author=M Jaffe;citation_author=E Zhen;citation_author=M Sommer;citation_journal_title=PLOS ONE;citation_volume=16;citation_number=16;citation_first_page=e0252946;citation_publication_date=2021;"/> <meta name="citation_reference" content="citation_title=Menstruation and homelessness: Challenges faced living in shelters and on the street in New York City.;citation_author=M Sommer;citation_author=C Gruer;citation_author=RC Smith;citation_author=A Maroko;citation_journal_title=Health Place;citation_volume=66;citation_number=66;citation_first_page=102431;citation_publication_date=2020;"/> <meta name="citation_reference" content="UNHCR. Who we protect. In: UNHCR [Internet]. 2024 [cited 5 Mar 2024]. Available: https://www.unhcr.org/about-unhcr/who-we-protect ."/> <meta name="citation_reference" content="citation_title=Amenorrhea during the reproductive years—is it safe;citation_author=M Schachter;citation_author=Z Shoham;citation_journal_title=Fertil Steril;citation_volume=62;citation_number=62;citation_first_page=1;citation_last_page=16;citation_publication_date=1994;"/> <meta name="citation_reference" content="citation_title=Amenorrhea-An abnormal cessation of normal menstrual cycle.;citation_author=NT Khan;citation_author=N Jameel;citation_journal_title=Clin J Obstet Gynecol;citation_volume=3;citation_number=3;citation_first_page=033;citation_last_page=036;citation_publication_date=2020;"/> <meta name="citation_reference" content="citation_title=Amenorrhea.;citation_author=G Nawaz;citation_author=AD Rogol;citation_publication_date=2023;"/> <meta name="citation_reference" content="citation_title=Substance use and psychotherapeutic medications: A likely contributor to menstrual disorders in women who are seropositive for human immunodeficiency virus.;citation_author=SD Harlow;citation_author=M Cohen;citation_author=SE Ohmit;citation_author=P Schuman;citation_author=S Cu-Uvin;citation_author=X Lin;citation_journal_title=Am J Obstet Gynecol;citation_volume=188;citation_number=188;citation_first_page=881;citation_last_page=886;citation_publication_date=2003;"/> <meta name="citation_reference" content="citation_title=Contraceptive Use Among Women Who Inject Drugs: Motivators, Barriers, and Unmet Needs.;citation_author=G Mburu;citation_author=J Ndimbii;citation_author=S Ayon;citation_author=O Mlewa;citation_author=M Mbizvo;citation_author=C Kihara;citation_journal_title=Womens Reprod Health.;citation_volume=5;citation_number=5;citation_first_page=99;citation_last_page=116;citation_publication_date=2018;"/> <meta name="citation_reference" content="citation_title=Amenorrhea: A Systematic Approach to Diagnosis and Management.;citation_author=DA Klein;citation_author=SL Paradise;citation_author=RM Reeder;citation_journal_title=Am Fam Physician.;citation_volume=100;citation_number=100;citation_first_page=39;citation_last_page=48;citation_publication_date=2019;"/> <meta name="citation_reference" content="citation_title=Menstrual Cycles and Stress.;citation_inbook_title=Encyclopedia of Stress;citation_author=R Suri;citation_author=L Altshuler;citation_first_page=706;citation_last_page=711;citation_publication_date=2007;citation_publisher=Academic Press"/>  <script type='text/javascript'> var googletag = googletag || {}; googletag.cmd = googletag.cmd || []; (function() { var gads = document.createElement('script'); gads.async = true; gads.type = 'text/javascript'; var useSSL = 'https:' == document.location.protocol; gads.src = (useSSL ? 'https:' : 'http:') + '//www.googletagservices.com/tag/js/gpt.js'; var node = document.getElementsByTagName('script')[0]; node.parentNode.insertBefore(gads, node); })(); </script>  <script id="doubleClickSetupScript" type='text/javascript'> googletag.cmd.push(function() { googletag.defineSlot('/75507958/PONE_728x90_ATF', [728, 90], 'div-gpt-ad-1458247671871-0').addService(googletag.pubads()); googletag.defineSlot('/75507958/PONE_160x600_BTF', [160, 600], 'div-gpt-ad-1458247671871-1').addService(googletag.pubads()); var personalizedAds = window.plosCookieConsent && window.plosCookieConsent.hasConsented('advertising'); googletag.pubads().setRequestNonPersonalizedAds(personalizedAds ? 0 : 1); googletag.pubads().enableSingleRequest(); googletag.enableServices(); }); </script> <script type="text/javascript"> var WombatConfig = WombatConfig || {}; WombatConfig.journalKey = "PLoSONE"; WombatConfig.journalName = "PLOS ONE"; WombatConfig.figurePath = "/plosone/article/figure/image"; WombatConfig.figShareInstitutionString = "plos"; WombatConfig.doiResolverPrefix = "https://dx.plos.org/"; </script> <script type="text/javascript"> var WombatConfig = WombatConfig || {}; WombatConfig.metrics = WombatConfig.metrics || {}; WombatConfig.metrics.referenceUrl = "http://lagotto.io/plos"; WombatConfig.metrics.googleScholarUrl = "https://scholar.google.com/scholar"; WombatConfig.metrics.googleScholarCitationUrl = WombatConfig.metrics.googleScholarUrl + "?hl=en&lr=&q="; WombatConfig.metrics.crossrefUrl = "https://www.crossref.org"; </script> <script defer="defer" src="/resource/js/defer.js?5d23b84e5e396356b27c"></script><script src="/resource/js/sync.js?5d23b84e5e396356b27c"></script> <script src="/resource/js/vendor/jquery.min.js" type="text/javascript"></script> <script type="text/javascript" src="https://widgets.figshare.com/static/figshare.js"></script> <script src="/resource/js/vendor/fastclick/lib/fastclick.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.js" type="text/javascript"></script> <script src="/resource/js/vendor/underscore-min.js" type="text/javascript"></script> <script src="/resource/js/vendor/underscore.string.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/moment.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery-ui-effects.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.tooltip.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.dropdown.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.tab.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.reveal.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.slider.js" type="text/javascript"></script> <script src="/resource/js/util/utils.js" type="text/javascript"></script> <script src="/resource/js/components/toggle.js" type="text/javascript"></script> <script src="/resource/js/components/truncate_elem.js" type="text/javascript"></script> <script src="/resource/js/components/tooltip_hover.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery.dotdotdot.js" type="text/javascript"></script>  <script> dataLayer = [{ 'mobileSite': 'false', 'desktopSite': 'true' }]; </script> <title>A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs | PLOS ONE</title> </head> <body class="article plosone">  <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-TP26BH" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript> <script> (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= '//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-TP26BH'); </script> <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-MQQMGF" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript> <script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start': new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0], j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src= '//www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f); })(window,document,'script','dataLayer','GTM-MQQMGF');</script>   <script> // from https://developers.hubspot.com/docs/reference/api/analytics-and-events/cookie-banner/cookie-banner-api#example-using-a-third-party-cookie-banner-to-control-hubspot-cookies window.disableHubSpotCookieBanner = true; window._hsp = window._hsp || []; window._hsp.push(['setHubSpotConsent', { analytics: window.plosCookieConsent?.hasConsented('analytics'), advertisement: window.plosCookieConsent?.hasConsented('advertising'), functionality: window.plosCookieConsent?.hasConsented('functionality') } ]); </script> <script type="text/javascript" id="hs-script-loader" async defer src="//js.hs-scripts.com/44092021.js"></script>   <script type="text/javascript"> ;window.NREUM||(NREUM={});NREUM.init={distributed_tracing:{enabled:true},privacy:{cookies_enabled:true},ajax:{deny_list:["bam.nr-data.net"]}}; window.NREUM||(NREUM={}),__nr_require=function(t,e,n){function r(n){if(!e[n]){var o=e[n]={exports:{}};t[n][0].call(o.exports,function(e){var o=t[n][1][e];return r(o||e)},o,o.exports)}return e[n].exports}if("function"==typeof __nr_require)return __nr_require;for(var o=0;o<n.length;o++)r(n[o]);return r}({1:[function(t,e,n){function r(t){try{s.console&&console.log(t)}catch(e){}}var o,i=t("ee"),a=t(32),s={};try{o=localStorage.getItem("__nr_flags").split(","),console&&"function"==typeof console.log&&(s.console=!0,o.indexOf("dev")!==-1&&(s.dev=!0),o.indexOf("nr_dev")!==-1&&(s.nrDev=!0))}catch(c){}s.nrDev&&i.on("internal-error",function(t){r(t.stack)}),s.dev&&i.on("fn-err",function(t,e,n){r(n.stack)}),s.dev&&(r("NR AGENT IN DEVELOPMENT MODE"),r("flags: "+a(s,function(t,e){return t}).join(", ")))},{}],2:[function(t,e,n){function r(t,e,n,r,s){try{l?l-=1:o(s||new UncaughtException(t,e,n),!0)}catch(f){try{i("ierr",[f,c.now(),!0])}catch(d){}}return"function"==typeof u&&u.apply(this,a(arguments))}function UncaughtException(t,e,n){this.message=t||"Uncaught error with no additional information",this.sourceURL=e,this.line=n}function o(t,e){var n=e?null:c.now();i("err",[t,n])}var i=t("handle"),a=t(33),s=t("ee"),c=t("loader"),f=t("gos"),u=window.onerror,d=!1,p="nr@seenError";if(!c.disabled){var l=0;c.features.err=!0,t(1),window.onerror=r;try{throw new Error}catch(h){"stack"in h&&(t(14),t(13),"addEventListener"in window&&t(7),c.xhrWrappable&&t(15),d=!0)}s.on("fn-start",function(t,e,n){d&&(l+=1)}),s.on("fn-err",function(t,e,n){d&&!n[p]&&(f(n,p,function(){return!0}),this.thrown=!0,o(n))}),s.on("fn-end",function(){d&&!this.thrown&&l>0&&(l-=1)}),s.on("internal-error",function(t){i("ierr",[t,c.now(),!0])})}},{}],3:[function(t,e,n){var r=t("loader");r.disabled||(r.features.ins=!0)},{}],4:[function(t,e,n){function r(){U++,L=g.hash,this[u]=y.now()}function o(){U--,g.hash!==L&&i(0,!0);var t=y.now();this[h]=~~this[h]+t-this[u],this[d]=t}function i(t,e){E.emit("newURL",[""+g,e])}function a(t,e){t.on(e,function(){this[e]=y.now()})}var s="-start",c="-end",f="-body",u="fn"+s,d="fn"+c,p="cb"+s,l="cb"+c,h="jsTime",m="fetch",v="addEventListener",w=window,g=w.location,y=t("loader");if(w[v]&&y.xhrWrappable&&!y.disabled){var x=t(11),b=t(12),E=t(9),R=t(7),O=t(14),T=t(8),P=t(15),S=t(10),M=t("ee"),N=M.get("tracer"),C=t(23);t(17),y.features.spa=!0;var L,U=0;M.on(u,r),b.on(p,r),S.on(p,r),M.on(d,o),b.on(l,o),S.on(l,o),M.buffer([u,d,"xhr-resolved"]),R.buffer([u]),O.buffer(["setTimeout"+c,"clearTimeout"+s,u]),P.buffer([u,"new-xhr","send-xhr"+s]),T.buffer([m+s,m+"-done",m+f+s,m+f+c]),E.buffer(["newURL"]),x.buffer([u]),b.buffer(["propagate",p,l,"executor-err","resolve"+s]),N.buffer([u,"no-"+u]),S.buffer(["new-jsonp","cb-start","jsonp-error","jsonp-end"]),a(T,m+s),a(T,m+"-done"),a(S,"new-jsonp"),a(S,"jsonp-end"),a(S,"cb-start"),E.on("pushState-end",i),E.on("replaceState-end",i),w[v]("hashchange",i,C(!0)),w[v]("load",i,C(!0)),w[v]("popstate",function(){i(0,U>1)},C(!0))}},{}],5:[function(t,e,n){function r(){var t=new PerformanceObserver(function(t,e){var n=t.getEntries();s(v,[n])});try{t.observe({entryTypes:["resource"]})}catch(e){}}function o(t){if(s(v,[window.performance.getEntriesByType(w)]),window.performance["c"+p])try{window.performance[h](m,o,!1)}catch(t){}else try{window.performance[h]("webkit"+m,o,!1)}catch(t){}}function i(t){}if(window.performance&&window.performance.timing&&window.performance.getEntriesByType){var a=t("ee"),s=t("handle"),c=t(14),f=t(13),u=t(6),d=t(23),p="learResourceTimings",l="addEventListener",h="removeEventListener",m="resourcetimingbufferfull",v="bstResource",w="resource",g="-start",y="-end",x="fn"+g,b="fn"+y,E="bstTimer",R="pushState",O=t("loader");if(!O.disabled){O.features.stn=!0,t(9),"addEventListener"in window&&t(7);var T=NREUM.o.EV;a.on(x,function(t,e){var n=t[0];n instanceof T&&(this.bstStart=O.now())}),a.on(b,function(t,e){var n=t[0];n instanceof T&&s("bst",[n,e,this.bstStart,O.now()])}),c.on(x,function(t,e,n){this.bstStart=O.now(),this.bstType=n}),c.on(b,function(t,e){s(E,[e,this.bstStart,O.now(),this.bstType])}),f.on(x,function(){this.bstStart=O.now()}),f.on(b,function(t,e){s(E,[e,this.bstStart,O.now(),"requestAnimationFrame"])}),a.on(R+g,function(t){this.time=O.now(),this.startPath=location.pathname+location.hash}),a.on(R+y,function(t){s("bstHist",[location.pathname+location.hash,this.startPath,this.time])}),u()?(s(v,[window.performance.getEntriesByType("resource")]),r()):l in window.performance&&(window.performance["c"+p]?window.performance[l](m,o,d(!1)):window.performance[l]("webkit"+m,o,d(!1))),document[l]("scroll",i,d(!1)),document[l]("keypress",i,d(!1)),document[l]("click",i,d(!1))}}},{}],6:[function(t,e,n){e.exports=function(){return"PerformanceObserver"in window&&"function"==typeof window.PerformanceObserver}},{}],7:[function(t,e,n){function r(t){for(var e=t;e&&!e.hasOwnProperty(u);)e=Object.getPrototypeOf(e);e&&o(e)}function o(t){s.inPlace(t,[u,d],"-",i)}function i(t,e){return t[1]}var a=t("ee").get("events"),s=t("wrap-function")(a,!0),c=t("gos"),f=XMLHttpRequest,u="addEventListener",d="removeEventListener";e.exports=a,"getPrototypeOf"in Object?(r(document),r(window),r(f.prototype)):f.prototype.hasOwnProperty(u)&&(o(window),o(f.prototype)),a.on(u+"-start",function(t,e){var n=t[1];if(null!==n&&("function"==typeof n||"object"==typeof n)){var r=c(n,"nr@wrapped",function(){function t(){if("function"==typeof n.handleEvent)return n.handleEvent.apply(n,arguments)}var e={object:t,"function":n}[typeof n];return e?s(e,"fn-",null,e.name||"anonymous"):n});this.wrapped=t[1]=r}}),a.on(d+"-start",function(t){t[1]=this.wrapped||t[1]})},{}],8:[function(t,e,n){function r(t,e,n){var r=t[e];"function"==typeof r&&(t[e]=function(){var t=i(arguments),e={};o.emit(n+"before-start",[t],e);var a;e[m]&&e[m].dt&&(a=e[m].dt);var s=r.apply(this,t);return o.emit(n+"start",[t,a],s),s.then(function(t){return o.emit(n+"end",[null,t],s),t},function(t){throw o.emit(n+"end",[t],s),t})})}var o=t("ee").get("fetch"),i=t(33),a=t(32);e.exports=o;var s=window,c="fetch-",f=c+"body-",u=["arrayBuffer","blob","json","text","formData"],d=s.Request,p=s.Response,l=s.fetch,h="prototype",m="nr@context";d&&p&&l&&(a(u,function(t,e){r(d[h],e,f),r(p[h],e,f)}),r(s,"fetch",c),o.on(c+"end",function(t,e){var n=this;if(e){var r=e.headers.get("content-length");null!==r&&(n.rxSize=r),o.emit(c+"done",[null,e],n)}else o.emit(c+"done",[t],n)}))},{}],9:[function(t,e,n){var r=t("ee").get("history"),o=t("wrap-function")(r);e.exports=r;var i=window.history&&window.history.constructor&&window.history.constructor.prototype,a=window.history;i&&i.pushState&&i.replaceState&&(a=i),o.inPlace(a,["pushState","replaceState"],"-")},{}],10:[function(t,e,n){function r(t){function e(){f.emit("jsonp-end",[],l),t.removeEventListener("load",e,c(!1)),t.removeEventListener("error",n,c(!1))}function n(){f.emit("jsonp-error",[],l),f.emit("jsonp-end",[],l),t.removeEventListener("load",e,c(!1)),t.removeEventListener("error",n,c(!1))}var r=t&&"string"==typeof t.nodeName&&"script"===t.nodeName.toLowerCase();if(r){var o="function"==typeof t.addEventListener;if(o){var a=i(t.src);if(a){var d=s(a),p="function"==typeof d.parent[d.key];if(p){var l={};u.inPlace(d.parent,[d.key],"cb-",l),t.addEventListener("load",e,c(!1)),t.addEventListener("error",n,c(!1)),f.emit("new-jsonp",[t.src],l)}}}}}function o(){return"addEventListener"in window}function i(t){var e=t.match(d);return e?e[1]:null}function a(t,e){var n=t.match(l),r=n[1],o=n[3];return o?a(o,e[r]):e[r]}function s(t){var e=t.match(p);return e&&e.length>=3?{key:e[2],parent:a(e[1],window)}:{key:t,parent:window}}var c=t(23),f=t("ee").get("jsonp"),u=t("wrap-function")(f);if(e.exports=f,o()){var d=/[?&](?:callback|cb)=([^&#]+)/,p=/(.*)\.([^.]+)/,l=/^(\w+)(\.|$)(.*)$/,h=["appendChild","insertBefore","replaceChild"];Node&&Node.prototype&&Node.prototype.appendChild?u.inPlace(Node.prototype,h,"dom-"):(u.inPlace(HTMLElement.prototype,h,"dom-"),u.inPlace(HTMLHeadElement.prototype,h,"dom-"),u.inPlace(HTMLBodyElement.prototype,h,"dom-")),f.on("dom-start",function(t){r(t[0])})}},{}],11:[function(t,e,n){var r=t("ee").get("mutation"),o=t("wrap-function")(r),i=NREUM.o.MO;e.exports=r,i&&(window.MutationObserver=function(t){return this instanceof i?new i(o(t,"fn-")):i.apply(this,arguments)},MutationObserver.prototype=i.prototype)},{}],12:[function(t,e,n){function r(t){var e=i.context(),n=s(t,"executor-",e,null,!1),r=new f(n);return i.context(r).getCtx=function(){return e},r}var o=t("wrap-function"),i=t("ee").get("promise"),a=t("ee").getOrSetContext,s=o(i),c=t(32),f=NREUM.o.PR;e.exports=i,f&&(window.Promise=r,["all","race"].forEach(function(t){var e=f[t];f[t]=function(n){function r(t){return function(){i.emit("propagate",[null,!o],a,!1,!1),o=o||!t}}var o=!1;c(n,function(e,n){Promise.resolve(n).then(r("all"===t),r(!1))});var a=e.apply(f,arguments),s=f.resolve(a);return s}}),["resolve","reject"].forEach(function(t){var e=f[t];f[t]=function(t){var n=e.apply(f,arguments);return t!==n&&i.emit("propagate",[t,!0],n,!1,!1),n}}),f.prototype["catch"]=function(t){return this.then(null,t)},f.prototype=Object.create(f.prototype,{constructor:{value:r}}),c(Object.getOwnPropertyNames(f),function(t,e){try{r[e]=f[e]}catch(n){}}),o.wrapInPlace(f.prototype,"then",function(t){return function(){var e=this,n=o.argsToArray.apply(this,arguments),r=a(e);r.promise=e,n[0]=s(n[0],"cb-",r,null,!1),n[1]=s(n[1],"cb-",r,null,!1);var c=t.apply(this,n);return r.nextPromise=c,i.emit("propagate",[e,!0],c,!1,!1),c}}),i.on("executor-start",function(t){t[0]=s(t[0],"resolve-",this,null,!1),t[1]=s(t[1],"resolve-",this,null,!1)}),i.on("executor-err",function(t,e,n){t[1](n)}),i.on("cb-end",function(t,e,n){i.emit("propagate",[n,!0],this.nextPromise,!1,!1)}),i.on("propagate",function(t,e,n){this.getCtx&&!e||(this.getCtx=function(){if(t instanceof Promise)var e=i.context(t);return e&&e.getCtx?e.getCtx():this})}),r.toString=function(){return""+f})},{}],13:[function(t,e,n){var r=t("ee").get("raf"),o=t("wrap-function")(r),i="equestAnimationFrame";e.exports=r,o.inPlace(window,["r"+i,"mozR"+i,"webkitR"+i,"msR"+i],"raf-"),r.on("raf-start",function(t){t[0]=o(t[0],"fn-")})},{}],14:[function(t,e,n){function r(t,e,n){t[0]=a(t[0],"fn-",null,n)}function o(t,e,n){this.method=n,this.timerDuration=isNaN(t[1])?0:+t[1],t[0]=a(t[0],"fn-",this,n)}var i=t("ee").get("timer"),a=t("wrap-function")(i),s="setTimeout",c="setInterval",f="clearTimeout",u="-start",d="-";e.exports=i,a.inPlace(window,[s,"setImmediate"],s+d),a.inPlace(window,[c],c+d),a.inPlace(window,[f,"clearImmediate"],f+d),i.on(c+u,r),i.on(s+u,o)},{}],15:[function(t,e,n){function r(t,e){d.inPlace(e,["onreadystatechange"],"fn-",s)}function o(){var t=this,e=u.context(t);t.readyState>3&&!e.resolved&&(e.resolved=!0,u.emit("xhr-resolved",[],t)),d.inPlace(t,y,"fn-",s)}function i(t){x.push(t),m&&(E?E.then(a):w?w(a):(R=-R,O.data=R))}function a(){for(var t=0;t<x.length;t++)r([],x[t]);x.length&&(x=[])}function s(t,e){return e}function c(t,e){for(var n in t)e[n]=t[n];return e}t(7);var f=t("ee"),u=f.get("xhr"),d=t("wrap-function")(u),p=t(23),l=NREUM.o,h=l.XHR,m=l.MO,v=l.PR,w=l.SI,g="readystatechange",y=["onload","onerror","onabort","onloadstart","onloadend","onprogress","ontimeout"],x=[];e.exports=u;var b=window.XMLHttpRequest=function(t){var e=new h(t);try{u.emit("new-xhr",[e],e),e.addEventListener(g,o,p(!1))}catch(n){try{u.emit("internal-error",[n])}catch(r){}}return e};if(c(h,b),b.prototype=h.prototype,d.inPlace(b.prototype,["open","send"],"-xhr-",s),u.on("send-xhr-start",function(t,e){r(t,e),i(e)}),u.on("open-xhr-start",r),m){var E=v&&v.resolve();if(!w&&!v){var R=1,O=document.createTextNode(R);new m(a).observe(O,{characterData:!0})}}else f.on("fn-end",function(t){t[0]&&t[0].type===g||a()})},{}],16:[function(t,e,n){function r(t){if(!s(t))return null;var e=window.NREUM;if(!e.loader_config)return null;var n=(e.loader_config.accountID||"").toString()||null,r=(e.loader_config.agentID||"").toString()||null,f=(e.loader_config.trustKey||"").toString()||null;if(!n||!r)return null;var h=l.generateSpanId(),m=l.generateTraceId(),v=Date.now(),w={spanId:h,traceId:m,timestamp:v};return(t.sameOrigin||c(t)&&p())&&(w.traceContextParentHeader=o(h,m),w.traceContextStateHeader=i(h,v,n,r,f)),(t.sameOrigin&&!u()||!t.sameOrigin&&c(t)&&d())&&(w.newrelicHeader=a(h,m,v,n,r,f)),w}function o(t,e){return"00-"+e+"-"+t+"-01"}function i(t,e,n,r,o){var i=0,a="",s=1,c="",f="";return o+"@nr="+i+"-"+s+"-"+n+"-"+r+"-"+t+"-"+a+"-"+c+"-"+f+"-"+e}function a(t,e,n,r,o,i){var a="btoa"in window&&"function"==typeof window.btoa;if(!a)return null;var s={v:[0,1],d:{ty:"Browser",ac:r,ap:o,id:t,tr:e,ti:n}};return i&&r!==i&&(s.d.tk=i),btoa(JSON.stringify(s))}function s(t){return f()&&c(t)}function c(t){var e=!1,n={};if("init"in NREUM&&"distributed_tracing"in NREUM.init&&(n=NREUM.init.distributed_tracing),t.sameOrigin)e=!0;else if(n.allowed_origins instanceof Array)for(var r=0;r<n.allowed_origins.length;r++){var o=h(n.allowed_origins[r]);if(t.hostname===o.hostname&&t.protocol===o.protocol&&t.port===o.port){e=!0;break}}return e}function f(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.enabled}function u(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.exclude_newrelic_header}function d(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&NREUM.init.distributed_tracing.cors_use_newrelic_header!==!1}function p(){return"init"in NREUM&&"distributed_tracing"in NREUM.init&&!!NREUM.init.distributed_tracing.cors_use_tracecontext_headers}var l=t(29),h=t(18);e.exports={generateTracePayload:r,shouldGenerateTrace:s}},{}],17:[function(t,e,n){function r(t){var e=this.params,n=this.metrics;if(!this.ended){this.ended=!0;for(var r=0;r<p;r++)t.removeEventListener(d[r],this.listener,!1);e.aborted||(n.duration=a.now()-this.startTime,this.loadCaptureCalled||4!==t.readyState?null==e.status&&(e.status=0):i(this,t),n.cbTime=this.cbTime,s("xhr",[e,n,this.startTime,this.endTime,"xhr"],this))}}function o(t,e){var n=c(e),r=t.params;r.hostname=n.hostname,r.port=n.port,r.protocol=n.protocol,r.host=n.hostname+":"+n.port,r.pathname=n.pathname,t.parsedOrigin=n,t.sameOrigin=n.sameOrigin}function i(t,e){t.params.status=e.status;var n=v(e,t.lastSize);if(n&&(t.metrics.rxSize=n),t.sameOrigin){var r=e.getResponseHeader("X-NewRelic-App-Data");r&&(t.params.cat=r.split(", ").pop())}t.loadCaptureCalled=!0}var a=t("loader");if(a.xhrWrappable&&!a.disabled){var s=t("handle"),c=t(18),f=t(16).generateTracePayload,u=t("ee"),d=["load","error","abort","timeout"],p=d.length,l=t("id"),h=t(24),m=t(22),v=t(19),w=t(23),g=NREUM.o.REQ,y=window.XMLHttpRequest;a.features.xhr=!0,t(15),t(8),u.on("new-xhr",function(t){var e=this;e.totalCbs=0,e.called=0,e.cbTime=0,e.end=r,e.ended=!1,e.xhrGuids={},e.lastSize=null,e.loadCaptureCalled=!1,e.params=this.params||{},e.metrics=this.metrics||{},t.addEventListener("load",function(n){i(e,t)},w(!1)),h&&(h>34||h<10)||t.addEventListener("progress",function(t){e.lastSize=t.loaded},w(!1))}),u.on("open-xhr-start",function(t){this.params={method:t[0]},o(this,t[1]),this.metrics={}}),u.on("open-xhr-end",function(t,e){"loader_config"in NREUM&&"xpid"in NREUM.loader_config&&this.sameOrigin&&e.setRequestHeader("X-NewRelic-ID",NREUM.loader_config.xpid);var n=f(this.parsedOrigin);if(n){var r=!1;n.newrelicHeader&&(e.setRequestHeader("newrelic",n.newrelicHeader),r=!0),n.traceContextParentHeader&&(e.setRequestHeader("traceparent",n.traceContextParentHeader),n.traceContextStateHeader&&e.setRequestHeader("tracestate",n.traceContextStateHeader),r=!0),r&&(this.dt=n)}}),u.on("send-xhr-start",function(t,e){var n=this.metrics,r=t[0],o=this;if(n&&r){var i=m(r);i&&(n.txSize=i)}this.startTime=a.now(),this.listener=function(t){try{"abort"!==t.type||o.loadCaptureCalled||(o.params.aborted=!0),("load"!==t.type||o.called===o.totalCbs&&(o.onloadCalled||"function"!=typeof e.onload))&&o.end(e)}catch(n){try{u.emit("internal-error",[n])}catch(r){}}};for(var s=0;s<p;s++)e.addEventListener(d[s],this.listener,w(!1))}),u.on("xhr-cb-time",function(t,e,n){this.cbTime+=t,e?this.onloadCalled=!0:this.called+=1,this.called!==this.totalCbs||!this.onloadCalled&&"function"==typeof n.onload||this.end(n)}),u.on("xhr-load-added",function(t,e){var n=""+l(t)+!!e;this.xhrGuids&&!this.xhrGuids[n]&&(this.xhrGuids[n]=!0,this.totalCbs+=1)}),u.on("xhr-load-removed",function(t,e){var n=""+l(t)+!!e;this.xhrGuids&&this.xhrGuids[n]&&(delete this.xhrGuids[n],this.totalCbs-=1)}),u.on("xhr-resolved",function(){this.endTime=a.now()}),u.on("addEventListener-end",function(t,e){e instanceof y&&"load"===t[0]&&u.emit("xhr-load-added",[t[1],t[2]],e)}),u.on("removeEventListener-end",function(t,e){e instanceof y&&"load"===t[0]&&u.emit("xhr-load-removed",[t[1],t[2]],e)}),u.on("fn-start",function(t,e,n){e instanceof y&&("onload"===n&&(this.onload=!0),("load"===(t[0]&&t[0].type)||this.onload)&&(this.xhrCbStart=a.now()))}),u.on("fn-end",function(t,e){this.xhrCbStart&&u.emit("xhr-cb-time",[a.now()-this.xhrCbStart,this.onload,e],e)}),u.on("fetch-before-start",function(t){function e(t,e){var n=!1;return e.newrelicHeader&&(t.set("newrelic",e.newrelicHeader),n=!0),e.traceContextParentHeader&&(t.set("traceparent",e.traceContextParentHeader),e.traceContextStateHeader&&t.set("tracestate",e.traceContextStateHeader),n=!0),n}var n,r=t[1]||{};"string"==typeof t[0]?n=t[0]:t[0]&&t[0].url?n=t[0].url:window.URL&&t[0]&&t[0]instanceof URL&&(n=t[0].href),n&&(this.parsedOrigin=c(n),this.sameOrigin=this.parsedOrigin.sameOrigin);var o=f(this.parsedOrigin);if(o&&(o.newrelicHeader||o.traceContextParentHeader))if("string"==typeof t[0]||window.URL&&t[0]&&t[0]instanceof URL){var i={};for(var a in r)i[a]=r[a];i.headers=new Headers(r.headers||{}),e(i.headers,o)&&(this.dt=o),t.length>1?t[1]=i:t.push(i)}else t[0]&&t[0].headers&&e(t[0].headers,o)&&(this.dt=o)}),u.on("fetch-start",function(t,e){this.params={},this.metrics={},this.startTime=a.now(),this.dt=e,t.length>=1&&(this.target=t[0]),t.length>=2&&(this.opts=t[1]);var n,r=this.opts||{},i=this.target;"string"==typeof i?n=i:"object"==typeof i&&i instanceof g?n=i.url:window.URL&&"object"==typeof i&&i instanceof URL&&(n=i.href),o(this,n);var s=(""+(i&&i instanceof g&&i.method||r.method||"GET")).toUpperCase();this.params.method=s,this.txSize=m(r.body)||0}),u.on("fetch-done",function(t,e){this.endTime=a.now(),this.params||(this.params={}),this.params.status=e?e.status:0;var n;"string"==typeof this.rxSize&&this.rxSize.length>0&&(n=+this.rxSize);var r={txSize:this.txSize,rxSize:n,duration:a.now()-this.startTime};s("xhr",[this.params,r,this.startTime,this.endTime,"fetch"],this)})}},{}],18:[function(t,e,n){var r={};e.exports=function(t){if(t in r)return r[t];var e=document.createElement("a"),n=window.location,o={};e.href=t,o.port=e.port;var i=e.href.split("://");!o.port&&i[1]&&(o.port=i[1].split("/")[0].split("@").pop().split(":")[1]),o.port&&"0"!==o.port||(o.port="https"===i[0]?"443":"80"),o.hostname=e.hostname||n.hostname,o.pathname=e.pathname,o.protocol=i[0],"/"!==o.pathname.charAt(0)&&(o.pathname="/"+o.pathname);var a=!e.protocol||":"===e.protocol||e.protocol===n.protocol,s=e.hostname===document.domain&&e.port===n.port;return o.sameOrigin=a&&(!e.hostname||s),"/"===o.pathname&&(r[t]=o),o}},{}],19:[function(t,e,n){function r(t,e){var n=t.responseType;return"json"===n&&null!==e?e:"arraybuffer"===n||"blob"===n||"json"===n?o(t.response):"text"===n||""===n||void 0===n?o(t.responseText):void 0}var o=t(22);e.exports=r},{}],20:[function(t,e,n){function r(){}function o(t,e,n,r){return function(){return u.recordSupportability("API/"+e+"/called"),i(t+e,[f.now()].concat(s(arguments)),n?null:this,r),n?void 0:this}}var i=t("handle"),a=t(32),s=t(33),c=t("ee").get("tracer"),f=t("loader"),u=t(25),d=NREUM;"undefined"==typeof window.newrelic&&(newrelic=d);var p=["setPageViewName","setCustomAttribute","setErrorHandler","finished","addToTrace","inlineHit","addRelease"],l="api-",h=l+"ixn-";a(p,function(t,e){d[e]=o(l,e,!0,"api")}),d.addPageAction=o(l,"addPageAction",!0),d.setCurrentRouteName=o(l,"routeName",!0),e.exports=newrelic,d.interaction=function(){return(new r).get()};var m=r.prototype={createTracer:function(t,e){var n={},r=this,o="function"==typeof e;return i(h+"tracer",[f.now(),t,n],r),function(){if(c.emit((o?"":"no-")+"fn-start",[f.now(),r,o],n),o)try{return e.apply(this,arguments)}catch(t){throw c.emit("fn-err",[arguments,this,t],n),t}finally{c.emit("fn-end",[f.now()],n)}}}};a("actionText,setName,setAttribute,save,ignore,onEnd,getContext,end,get".split(","),function(t,e){m[e]=o(h,e)}),newrelic.noticeError=function(t,e){"string"==typeof t&&(t=new Error(t)),u.recordSupportability("API/noticeError/called"),i("err",[t,f.now(),!1,e])}},{}],21:[function(t,e,n){function r(t){if(NREUM.init){for(var e=NREUM.init,n=t.split("."),r=0;r<n.length-1;r++)if(e=e[n[r]],"object"!=typeof e)return;return e=e[n[n.length-1]]}}e.exports={getConfiguration:r}},{}],22:[function(t,e,n){e.exports=function(t){if("string"==typeof t&&t.length)return t.length;if("object"==typeof t){if("undefined"!=typeof ArrayBuffer&&t instanceof ArrayBuffer&&t.byteLength)return t.byteLength;if("undefined"!=typeof Blob&&t instanceof Blob&&t.size)return t.size;if(!("undefined"!=typeof FormData&&t instanceof FormData))try{return JSON.stringify(t).length}catch(e){return}}}},{}],23:[function(t,e,n){var r=!1;try{var o=Object.defineProperty({},"passive",{get:function(){r=!0}});window.addEventListener("testPassive",null,o),window.removeEventListener("testPassive",null,o)}catch(i){}e.exports=function(t){return r?{passive:!0,capture:!!t}:!!t}},{}],24:[function(t,e,n){var r=0,o=navigator.userAgent.match(/Firefox[\/\s](\d+\.\d+)/);o&&(r=+o[1]),e.exports=r},{}],25:[function(t,e,n){function r(t,e){var n=[a,t,{name:t},e];return i("storeMetric",n,null,"api"),n}function o(t,e){var n=[s,t,{name:t},e];return i("storeEventMetrics",n,null,"api"),n}var i=t("handle"),a="sm",s="cm";e.exports={constants:{SUPPORTABILITY_METRIC:a,CUSTOM_METRIC:s},recordSupportability:r,recordCustom:o}},{}],26:[function(t,e,n){function r(){return s.exists&&performance.now?Math.round(performance.now()):(i=Math.max((new Date).getTime(),i))-a}function o(){return i}var i=(new Date).getTime(),a=i,s=t(34);e.exports=r,e.exports.offset=a,e.exports.getLastTimestamp=o},{}],27:[function(t,e,n){function r(t){return!(!t||!t.protocol||"file:"===t.protocol)}e.exports=r},{}],28:[function(t,e,n){function r(t,e){var n=t.getEntries();n.forEach(function(t){"first-paint"===t.name?p("timing",["fp",Math.floor(t.startTime)]):"first-contentful-paint"===t.name&&p("timing",["fcp",Math.floor(t.startTime)])})}function o(t,e){var n=t.getEntries();if(n.length>0){var r=n[n.length-1];if(c&&c<r.startTime)return;p("lcp",[r])}}function i(t){t.getEntries().forEach(function(t){t.hadRecentInput||p("cls",[t])})}function a(t){if(t instanceof v&&!g){var e=Math.round(t.timeStamp),n={type:t.type};e<=l.now()?n.fid=l.now()-e:e>l.offset&&e<=Date.now()?(e-=l.offset,n.fid=l.now()-e):e=l.now(),g=!0,p("timing",["fi",e,n])}}function s(t){"hidden"===t&&(c=l.now(),p("pageHide",[c]))}if(!("init"in NREUM&&"page_view_timing"in NREUM.init&&"enabled"in NREUM.init.page_view_timing&&NREUM.init.page_view_timing.enabled===!1)){var c,f,u,d,p=t("handle"),l=t("loader"),h=t(31),m=t(23),v=NREUM.o.EV;if("PerformanceObserver"in window&&"function"==typeof window.PerformanceObserver){f=new PerformanceObserver(r);try{f.observe({entryTypes:["paint"]})}catch(w){}u=new PerformanceObserver(o);try{u.observe({entryTypes:["largest-contentful-paint"]})}catch(w){}d=new PerformanceObserver(i);try{d.observe({type:"layout-shift",buffered:!0})}catch(w){}}if("addEventListener"in document){var g=!1,y=["click","keydown","mousedown","pointerdown","touchstart"];y.forEach(function(t){document.addEventListener(t,a,m(!1))})}h(s)}},{}],29:[function(t,e,n){function r(){function t(){return e?15&e[n++]:16*Math.random()|0}var e=null,n=0,r=window.crypto||window.msCrypto;r&&r.getRandomValues&&(e=r.getRandomValues(new Uint8Array(31)));for(var o,i="xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx",a="",s=0;s<i.length;s++)o=i[s],"x"===o?a+=t().toString(16):"y"===o?(o=3&t()|8,a+=o.toString(16)):a+=o;return a}function o(){return a(16)}function i(){return a(32)}function a(t){function e(){return n?15&n[r++]:16*Math.random()|0}var n=null,r=0,o=window.crypto||window.msCrypto;o&&o.getRandomValues&&Uint8Array&&(n=o.getRandomValues(new Uint8Array(31)));for(var i=[],a=0;a<t;a++)i.push(e().toString(16));return i.join("")}e.exports={generateUuid:r,generateSpanId:o,generateTraceId:i}},{}],30:[function(t,e,n){function r(t,e){if(!o)return!1;if(t!==o)return!1;if(!e)return!0;if(!i)return!1;for(var n=i.split("."),r=e.split("."),a=0;a<r.length;a++)if(r[a]!==n[a])return!1;return!0}var o=null,i=null,a=/Version\/(\S+)\s+Safari/;if(navigator.userAgent){var s=navigator.userAgent,c=s.match(a);c&&s.indexOf("Chrome")===-1&&s.indexOf("Chromium")===-1&&(o="Safari",i=c[1])}e.exports={agent:o,version:i,match:r}},{}],31:[function(t,e,n){function r(t){function e(){t(s&&document[s]?document[s]:document[i]?"hidden":"visible")}"addEventListener"in document&&a&&document.addEventListener(a,e,o(!1))}var o=t(23);e.exports=r;var i,a,s;"undefined"!=typeof document.hidden?(i="hidden",a="visibilitychange",s="visibilityState"):"undefined"!=typeof document.msHidden?(i="msHidden",a="msvisibilitychange"):"undefined"!=typeof document.webkitHidden&&(i="webkitHidden",a="webkitvisibilitychange",s="webkitVisibilityState")},{}],32:[function(t,e,n){function r(t,e){var n=[],r="",i=0;for(r in t)o.call(t,r)&&(n[i]=e(r,t[r]),i+=1);return n}var o=Object.prototype.hasOwnProperty;e.exports=r},{}],33:[function(t,e,n){function r(t,e,n){e||(e=0),"undefined"==typeof n&&(n=t?t.length:0);for(var r=-1,o=n-e||0,i=Array(o<0?0:o);++r<o;)i[r]=t[e+r];return i}e.exports=r},{}],34:[function(t,e,n){e.exports={exists:"undefined"!=typeof window.performance&&window.performance.timing&&"undefined"!=typeof window.performance.timing.navigationStart}},{}],ee:[function(t,e,n){function r(){}function o(t){function e(t){return t&&t instanceof r?t:t?f(t,c,a):a()}function n(n,r,o,i,a){if(a!==!1&&(a=!0),!l.aborted||i){t&&a&&t(n,r,o);for(var s=e(o),c=m(n),f=c.length,u=0;u<f;u++)c[u].apply(s,r);var p=d[y[n]];return p&&p.push([x,n,r,s]),s}}function i(t,e){g[t]=m(t).concat(e)}function h(t,e){var n=g[t];if(n)for(var r=0;r<n.length;r++)n[r]===e&&n.splice(r,1)}function m(t){return g[t]||[]}function v(t){return p[t]=p[t]||o(n)}function w(t,e){l.aborted||u(t,function(t,n){e=e||"feature",y[n]=e,e in d||(d[e]=[])})}var g={},y={},x={on:i,addEventListener:i,removeEventListener:h,emit:n,get:v,listeners:m,context:e,buffer:w,abort:s,aborted:!1};return x}function i(t){return f(t,c,a)}function a(){return new r}function s(){(d.api||d.feature)&&(l.aborted=!0,d=l.backlog={})}var c="nr@context",f=t("gos"),u=t(32),d={},p={},l=e.exports=o();e.exports.getOrSetContext=i,l.backlog=d},{}],gos:[function(t,e,n){function r(t,e,n){if(o.call(t,e))return t[e];var r=n();if(Object.defineProperty&&Object.keys)try{return Object.defineProperty(t,e,{value:r,writable:!0,enumerable:!1}),r}catch(i){}return t[e]=r,r}var o=Object.prototype.hasOwnProperty;e.exports=r},{}],handle:[function(t,e,n){function r(t,e,n,r){o.buffer([t],r),o.emit(t,e,n)}var o=t("ee").get("handle");e.exports=r,r.ee=o},{}],id:[function(t,e,n){function r(t){var e=typeof t;return!t||"object"!==e&&"function"!==e?-1:t===window?0:a(t,i,function(){return o++})}var o=1,i="nr@id",a=t("gos");e.exports=r},{}],loader:[function(t,e,n){function r(){if(!P++){var t=T.info=NREUM.info,e=v.getElementsByTagName("script")[0];if(setTimeout(f.abort,3e4),!(t&&t.licenseKey&&t.applicationID&&e))return f.abort();c(R,function(e,n){t[e]||(t[e]=n)});var n=a();s("mark",["onload",n+T.offset],null,"api"),s("timing",["load",n]);var r=v.createElement("script");0===t.agent.indexOf("http://")||0===t.agent.indexOf("https://")?r.src=t.agent:r.src=h+"://"+t.agent,e.parentNode.insertBefore(r,e)}}function o(){"complete"===v.readyState&&i()}function i(){s("mark",["domContent",a()+T.offset],null,"api")}var a=t(26),s=t("handle"),c=t(32),f=t("ee"),u=t(30),d=t(27),p=t(21),l=t(23),h=p.getConfiguration("ssl")===!1?"http":"https",m=window,v=m.document,w="addEventListener",g="attachEvent",y=m.XMLHttpRequest,x=y&&y.prototype,b=!d(m.location);NREUM.o={ST:setTimeout,SI:m.setImmediate,CT:clearTimeout,XHR:y,REQ:m.Request,EV:m.Event,PR:m.Promise,MO:m.MutationObserver};var E=""+location,R={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",agent:"js-agent.newrelic.com/nr-spa-1212.min.js"},O=y&&x&&x[w]&&!/CriOS/.test(navigator.userAgent),T=e.exports={offset:a.getLastTimestamp(),now:a,origin:E,features:{},xhrWrappable:O,userAgent:u,disabled:b};if(!b){t(20),t(28),v[w]?(v[w]("DOMContentLoaded",i,l(!1)),m[w]("load",r,l(!1))):(v[g]("onreadystatechange",o),m[g]("onload",r)),s("mark",["firstbyte",a.getLastTimestamp()],null,"api");var P=0}},{}],"wrap-function":[function(t,e,n){function r(t,e){function n(e,n,r,c,f){function nrWrapper(){var i,a,u,p;try{a=this,i=d(arguments),u="function"==typeof r?r(i,a):r||{}}catch(l){o([l,"",[i,a,c],u],t)}s(n+"start",[i,a,c],u,f);try{return p=e.apply(a,i)}catch(h){throw s(n+"err",[i,a,h],u,f),h}finally{s(n+"end",[i,a,p],u,f)}}return a(e)?e:(n||(n=""),nrWrapper[p]=e,i(e,nrWrapper,t),nrWrapper)}function r(t,e,r,o,i){r||(r="");var s,c,f,u="-"===r.charAt(0);for(f=0;f<e.length;f++)c=e[f],s=t[c],a(s)||(t[c]=n(s,u?c+r:r,o,c,i))}function s(n,r,i,a){if(!h||e){var s=h;h=!0;try{t.emit(n,r,i,e,a)}catch(c){o([c,n,r,i],t)}h=s}}return t||(t=u),n.inPlace=r,n.flag=p,n}function o(t,e){e||(e=u);try{e.emit("internal-error",t)}catch(n){}}function i(t,e,n){if(Object.defineProperty&&Object.keys)try{var r=Object.keys(t);return r.forEach(function(n){Object.defineProperty(e,n,{get:function(){return t[n]},set:function(e){return t[n]=e,e}})}),e}catch(i){o([i],n)}for(var a in t)l.call(t,a)&&(e[a]=t[a]);return e}function a(t){return!(t&&t instanceof Function&&t.apply&&!t[p])}function s(t,e){var n=e(t);return n[p]=t,i(t,n,u),n}function c(t,e,n){var r=t[e];t[e]=s(r,n)}function f(){for(var t=arguments.length,e=new Array(t),n=0;n<t;++n)e[n]=arguments[n];return e}var u=t("ee"),d=t(33),p="nr@original",l=Object.prototype.hasOwnProperty,h=!1;e.exports=r,e.exports.wrapFunction=s,e.exports.wrapInPlace=c,e.exports.argsToArray=f},{}]},{},["loader",2,17,5,3,4]); ;NREUM.loader_config={accountID:"804283",trustKey:"804283",agentID:"402703674",licenseKey:"cf99e8d2a3",applicationID:"402703674"} ;NREUM.info={beacon:"bam.nr-data.net",errorBeacon:"bam.nr-data.net",licenseKey:"cf99e8d2a3", // Modified this value from the generated script, to pass prod vs dev applicationID: window.location.hostname.includes('journals.plos.org') ? "402703674" : "402694889", sa:1} </script>  <header> <div id="topslot" class="head-top"> <a id="skip-to-content" tabindex="0" class="button" href="#main-content"> Skip to main content </a> <div class="center"> <div class="title">Advertisement</div>  <div class='advertisement' id='div-gpt-ad-1458247671871-0' style='width:728px; height:90px;'> <script type='text/javascript'> googletag.cmd.push(function() { googletag.display('div-gpt-ad-1458247671871-0'); }); </script> </div> </div> </div> <div id="user" class="nav" data-user-management-url="https://community.plos.org"> </div> <div id="pagehdr"> <nav class="nav-main"> <h1 class="logo"> <a href="/plosone/.">PLOS ONE</a> </h1> <section class="top-bar-section"> <ul class="nav-elements"> <li class="multi-col-parent menu-section-header has-dropdown" id="publish"> Publish <div class="dropdown mega "> <ul class="multi-col" id="publish-dropdown-list"> <li class="menu-section-header " id="submissions"> <span class="menu-section-header-title"> Submissions </span> <ul class="menu-section " id="submissions-dropdown-list"> <li> <a href="/plosone/s/getting-started" >Getting Started</a> </li> <li> <a href="/plosone/s/submission-guidelines" >Submission Guidelines</a> </li> <li> <a href="/plosone/s/figures" >Figures</a> </li> <li> <a href="/plosone/s/tables" >Tables</a> </li> <li> <a href="/plosone/s/supporting-information" >Supporting Information</a> </li> <li> <a href="/plosone/s/latex" >LaTeX</a> </li> <li> <a href="/plosone/s/what-we-publish" >What We Publish</a> </li> <li> <a href="/plosone/s/preprints" >Preprints</a> </li> <li> <a href="/plosone/s/revising-your-manuscript" >Revising Your Manuscript</a> </li> <li> <a href="/plosone/s/submit-now" >Submit Now</a> </li> <li> <a href="https://collections.plos.org/s/calls-for-papers" >Calls for Papers</a> </li> </ul> </li> <li class="menu-section-header " id="policies"> <span class="menu-section-header-title"> Policies </span> <ul class="menu-section " id="policies-dropdown-list"> <li> <a href="/plosone/s/best-practices-in-research-reporting" >Best Practices in Research Reporting</a> </li> <li> <a href="/plosone/s/human-subjects-research" >Human Subjects Research</a> </li> <li> <a href="/plosone/s/animal-research" >Animal Research</a> </li> <li> <a href="/plosone/s/competing-interests" >Competing Interests</a> </li> <li> <a href="/plosone/s/disclosure-of-funding-sources" >Disclosure of Funding Sources</a> </li> <li> <a href="/plosone/s/licenses-and-copyright" >Licenses and Copyright</a> </li> <li> <a href="/plosone/s/data-availability" >Data Availability</a> </li> <li> <a href="/plosone/s/complementary-research" >Complementary Research</a> </li> <li> <a href="/plosone/s/materials-software-and-code-sharing" >Materials, Software and Code Sharing</a> </li> <li> <a href="/plosone/s/ethical-publishing-practice" >Ethical Publishing Practice</a> </li> <li> <a href="/plosone/s/authorship" >Authorship</a> </li> <li> <a href="/plosone/s/corrections-expressions-of-concern-and-retractions" >Corrections, Expressions of Concern, and Retractions</a> </li> </ul> </li> <li class="menu-section-header " id="manuscript-review-and-publication"> <span class="menu-section-header-title"> Manuscript Review and Publication </span> <ul class="menu-section " id="manuscript-review-and-publication-dropdown-list"> <li> <a href="/plosone/s/criteria-for-publication" >Criteria for Publication</a> </li> <li> <a href="/plosone/s/editorial-and-peer-review-process" >Editorial and Peer Review Process</a> </li> <li> <a href="https://plos.org/resources/editor-center" >Editor Center</a> </li> <li> <a href="/plosone/s/resources-for-editors" >Resources for Editors</a> </li> <li> <a href="/plosone/s/reviewer-guidelines" >Guidelines for Reviewers</a> </li> <li> <a href="/plosone/s/accepted-manuscripts" >Accepted Manuscripts</a> </li> <li> <a href="/plosone/s/comments" >Comments</a> </li> </ul> </li> </ul> <div class="calloutcontainer"> <h3 class="callout-headline">Submit Your Manuscript</h3> <div class="action-contain"> <p class="callout-content"> Discover a faster, simpler path to publishing in a high-quality journal. <em>PLOS ONE</em> promises fair, rigorous peer review, broad scope, and wide readership – a perfect fit for your research every time. </p> <p class="button-contain special"> <a class="button button-default" href="/plosone/static/publish"> Learn More </a> <a class="button-link" href="https://www.editorialmanager.com/pone/default.asp"> Submit Now </a> </p> </div>  </div> </div> </li> <li class="menu-section-header has-dropdown " id="about"> <span class="menu-section-header-title"> About </span> <ul class="menu-section dropdown " id="about-dropdown-list"> <li> <a href="/plosone/static/publish" >Why Publish with PLOS ONE</a> </li> <li> <a href="/plosone/s/journal-information" >Journal Information</a> </li> <li> <a href="/plosone/s/staff-editors" >Staff Editors</a> </li> <li> <a href="/plosone/static/editorial-board" >Editorial Board</a> </li> <li> <a href="/plosone/s/section-editors" >Section Editors</a> </li> <li> <a href="/plosone/s/advisory-groups" >Advisory Groups</a> </li> <li> <a href="/plosone/s/find-and-read-articles" >Find and Read Articles</a> </li> <li> <a href="/plosone/s/publishing-information" >Publishing Information</a> </li> <li> <a href="https://plos.org/publication-fees" >Publication Fees</a> </li> <li> <a href="https://plos.org/press-and-media" >Press and Media</a> </li> <li> <a href="/plosone/s/contact" >Contact</a> </li> </ul> </li> <li data-js-tooltip-hover="trigger" class="subject-area menu-section-header"> Browse </li> <script src="/resource/js/vendor/jquery.hoverIntent.js" type="text/javascript"></script> <script src="/resource/js/components/menu_drop.js" type="text/javascript"></script> <script src="/resource/js/components/hover_delay.js" type="text/javascript"></script> <li id="navsearch" class="head-search"> <form name="searchForm" action="/plosone/search" method="get"> <fieldset> <legend>Search</legend> <label for="search">Search</label> <div class="search-contain"> <input id="search" type="text" name="q" placeholder="SEARCH" required/> <button id="headerSearchButton" type="submit" aria-label="Submit search"> <i title="Submit search" class="search-icon"></i> </button> </div> </fieldset> <input type="hidden" name="filterJournals" value="PLoSONE"/> </form> <a id="advSearch" href="/plosone/search"> advanced search </a> <script src="/resource/js/components/placeholder_style.js" type="text/javascript"></script> </li> </ul> </section> </nav> </div> </header> <section id="taxonomyContainer"> <script src="/resource/js/taxonomy-browser.js" type="text/javascript"></script> <div id="taxonomy-browser" class="areas" data-search-url="/plosone/browse"> <div class="wrapper"> <div class="taxonomy-header"> Browse Subject Areas <div id="subjInfo">?</div> <div id="subjInfoText"> <p>Click through the PLOS taxonomy to find articles in your field.</p> <p>For more information about PLOS Subject Areas, click <a href="https://github.com/PLOS/plos-thesaurus/blob/master/README.md" target="_blank" title="Link opens in new window">here</a>. </p> </div> </div> <div class="levels"> <div class="levels-container cf"> <div class="levels-position"></div> </div> <a href="#" class="prev"></a> <a href="#" class="next active"></a> </div> </div> <div class="taxonomy-browser-border-bottom"></div> </div> </section> <main id="main-content"> <div class="set-grid"> <header class="title-block"> <script src="/resource/js/components/signposts.js" type="text/javascript"></script> <ul id="almSignposts" class="signposts"> <li id="loadingMetrics"> <p>Loading metrics</p> </li> </ul> <script type="text/template" id="signpostsGeneralErrorTemplate"> <li id="metricsError">Article metrics are unavailable at this time. Please try again later.</li> </script> <script type="text/template" id="signpostsNewArticleErrorTemplate"> <li></li><li></li><li id="tooSoon">Article metrics are unavailable for recently published articles.</li> </script> <script type="text/template" id="signpostsTemplate"> <li id="almSaves"> <%= s.numberFormat(saveCount, 0) %> <div class="tools" data-js-tooltip-hover="trigger"> <a class="metric-term" href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#savedHeader">Save</a> <p class="saves-tip" data-js-tooltip-hover="target"><a href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#savedHeader">Total Mendeley and Citeulike bookmarks.</a></p> </div> </li> <li id="almCitations"> <%= s.numberFormat(citationCount, 0) %> <div class="tools" data-js-tooltip-hover="trigger"> <a class="metric-term" href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#citedHeader">Citation</a> <p class="citations-tip" data-js-tooltip-hover="target"><a href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#citedHeader">Paper's citation count computed by Dimensions.</a></p> </div> </li> <li id="almViews"> <%= s.numberFormat(viewCount, 0) %> <div class="tools" data-js-tooltip-hover="trigger"> <a class="metric-term" href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#viewedHeader">View</a> <p class="views-tip" data-js-tooltip-hover="target"><a href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#viewedHeader">PLOS views and downloads.</a></p> </div> </li> <li id="almShares"> <%= s.numberFormat(shareCount, 0) %> <div class="tools" data-js-tooltip-hover="trigger"> <a class="metric-term" href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#discussedHeader">Share</a> <p class="shares-tip" data-js-tooltip-hover="target"><a href="/plosone/article/metrics?id=10.1371/journal.pone.0303378#discussedHeader">Sum of Facebook, Twitter, Reddit and Wikipedia activity.</a></p> </div> </li> </script> <div class="article-meta"> <div class="classifications"> <p class="license-short" id="licenseShort">Open Access</p> <p class="peer-reviewed" id="peerReviewed">Peer-reviewed</p> <div class="article-type" > <p class="type-article" id="artType">Research Article</p> </div> </div> </div> <div class="article-title-etc"> <div class="title-authors"> <h1 id="artTitle"><?xml version="1.0" encoding="UTF-8"?>A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs</h1> <ul class="author-list clearfix" data-js-tooltip="tooltip_container" id="author-list"> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="0" class="author-name" > Alhelí Calderón-Villarreal <span class="email"> </span>,</a> <div id="author-meta-0" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Conceptualization, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing </p> <p id="authCorresponding-0"> <span class="email">* E-mail:</span> <a href="mailto:alheli.calderon@gmail.com">alheli.calderon@gmail.com</a>, <a href="mailto:acv001@health.ucsd.edu">acv001@health.ucsd.edu</a>, <a href="mailto:acalderonvilla0207@sdsu.edu">acalderonvilla0207@sdsu.edu</a></p> <p id="authAffiliations-0"><span class="type">Affiliations</span> Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego (UCSD), San Diego, California, United States of America, School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America </p> <div> <p class="orcid" id="authOrcid-0"> <span> <a id="connect-orcid-link" href="https://orcid.org/0000-0003-1064-7097" target="_blank" title="ORCID Registry"> <img id="orcid-id-logo" src="/resource/img/orcid_16x16.png" width="16" height="16" alt="ORCID logo"/> https://orcid.org/0000-0003-1064-7097 </a> </span> </p> </div> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose0"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="1" class="author-name" > Lourdes Johanna Avelar Portillo,</a> <div id="author-meta-1" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Conceptualization, Investigation, Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-1"><span class="type">Affiliations</span> Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America, Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose1"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="2" class="author-name" > Daniela Abramovitz,</a> <div id="author-meta-2" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Data curation, Methodology, Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-2"><span class="type">Affiliation</span> Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose2"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="3" class="author-name" > Shira Goldenberg,</a> <div id="author-meta-3" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-3"><span class="type">Affiliation</span> School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose3"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="4" class="author-name" > Shawn Flanigan,</a> <div id="author-meta-4" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-4"><span class="type">Affiliation</span> School of Public Affairs, SDSU, San, Diego, California, United States of America </p> <div> <p class="orcid" id="authOrcid-4"> <span> <a id="connect-orcid-link" href="https://orcid.org/0000-0002-9502-9839" target="_blank" title="ORCID Registry"> <img id="orcid-id-logo" src="/resource/img/orcid_16x16.png" width="16" height="16" alt="ORCID logo"/> https://orcid.org/0000-0002-9502-9839 </a> </span> </p> </div> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose4"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="5" class="author-name" > Penelope J. E. Quintana,</a> <div id="author-meta-5" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-5"><span class="type">Affiliation</span> School of Public Health, San Diego State University (SDSU), San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose5"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="6" class="author-name" > Alicia Harvey-Vera,</a> <div id="author-meta-6" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Investigation, Project administration, Resources </p> <p id="authAffiliations-6"><span class="type">Affiliations</span> Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America, Universidad de Xochicalco, Tijuana, Baja California, Mexico </p> <div> <p class="orcid" id="authOrcid-6"> <span> <a id="connect-orcid-link" href="https://orcid.org/0000-0002-8708-8169" target="_blank" title="ORCID Registry"> <img id="orcid-id-logo" src="/resource/img/orcid_16x16.png" width="16" height="16" alt="ORCID logo"/> https://orcid.org/0000-0002-8708-8169 </a> </span> </p> </div> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose6"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="7" class="author-name" > Carlos F. Vera,</a> <div id="author-meta-7" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Investigation, Project administration </p> <p id="authAffiliations-7"><span class="type">Affiliation</span> Division of Global Health, Herbert Wertheim School of Public Health and Human Longevity Science, UCSD, San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose7"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="8" class="author-name" > Gudelia Rangel,</a> <div id="author-meta-8" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Funding acquisition, Project administration, Resources </p> <p id="authAffiliations-8"><span class="type">Affiliations</span> El Colegio de la Frontera Norte, Tijuana, Baja California, Mexico, Border Health Commission, Tijuana, Baja California, Mexico </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose8"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="9" class="author-name" > Steffanie A. Strathdee,</a> <div id="author-meta-9" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-9"><span class="type">Affiliation</span> Department of Medicine, Division of Infectious Diseases and Global Public Health, UCSD, San Diego, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose9"> ⨯ </a> </div> </li> <li data-js-tooltip="tooltip_trigger" > <a data-author-id="10" class="author-name" > Georgia L. Kayser</a> <div id="author-meta-10" class="author-info" data-js-tooltip="tooltip_target"> <p class="roles" id="authRoles"> <span class="type">Roles</span> Conceptualization, Methodology, Supervision, Validation, Writing – review & editing </p> <p id="authAffiliations-10"><span class="type">Affiliation</span> Benioff Homelessness and Housing Initiative, School of Medicine, University of California, San Francisco, San Francisco, California, United States of America </p> <a data-js-tooltip="tooltip_close" class="close" id="tooltipClose10"> ⨯ </a> </div> </li> </ul> <script src="/resource/js/components/tooltip.js" type="text/javascript"></script> </div> <div id="floatTitleTop" data-js-floater="title_author" class="float-title" role="presentation"> <div class="set-grid"> <div class="float-title-inner"> <h1><?xml version="1.0" encoding="UTF-8"?>A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs</h1> <ul id="floatAuthorList" data-js-floater="floated_authors"> <li data-float-index="1">Alhelí Calderón-Villarreal,  </li> <li data-float-index="2">Lourdes Johanna Avelar Portillo,  </li> <li data-float-index="3">Daniela Abramovitz,  </li> <li data-float-index="4">Shira Goldenberg,  </li> <li data-float-index="5">Shawn Flanigan,  </li> <li data-float-index="6">Penelope J. E. Quintana,  </li> <li data-float-index="7">Alicia Harvey-Vera,  </li> <li data-float-index="8">Carlos F. Vera,  </li> <li data-float-index="9">Gudelia Rangel,  </li> <li data-float-index="10">Steffanie A. Strathdee </ul> </div> <div class="logo-close" id="titleTopCloser"> <img src="/resource/img/logo-plos.png" style="height: 2em" alt="PLOS" /> <div class="close-floater" title="close">x</div> </div> </div> </div> <ul class="date-doi"> <li id="artPubDate">Published: May 10, 2024</li> <li id="artDoi"> <a href="https://doi.org/10.1371/journal.pone.0303378">https://doi.org/10.1371/journal.pone.0303378</a> </li> <li class="flex-spacer"></li> </ul> </div> <div> </div> </header> <section class="article-body"> <ul class="article-tabs"> <li class="tab-title active" id="tabArticle"> <a href="/plosone/article?id=10.1371/journal.pone.0303378" class="article-tab-1">Article</a> </li> <li class="tab-title " id="tabAuthors"> <a href="/plosone/article/authors?id=10.1371/journal.pone.0303378" class="article-tab-2">Authors</a> </li> <li class="tab-title " id="tabMetrics"> <a href="/plosone/article/metrics?id=10.1371/journal.pone.0303378" class="article-tab-3">Metrics</a> </li> <li class="tab-title " id="tabComments"> <a href="/plosone/article/comments?id=10.1371/journal.pone.0303378" class="article-tab-4">Comments</a> </li> <li class="tab-title" id="tabRelated"> <a class="article-tab-5" id="tabRelated-link">Media Coverage</a> <script>$(document).ready(function() { $.getMediaLink("10.1371/journal.pone.0303378").then(function (url) { $("#tabRelated-link").attr("href", url) } ) })</script> </li> </ul> <div class="article-container"> <div id="nav-article"> <ul class="nav-secondary"> <li class="nav-comments" id="nav-comments"> <a href="article/comments?id=10.1371/journal.pone.0303378">Reader Comments</a> </li> <li id="nav-figures"><a href="#" data-doi="10.1371/journal.pone.0303378">Figures</a></li> </ul> <div id="nav-data-linking" data-data-url=""> </div> </div> <script src="/resource/js/components/scroll.js" type="text/javascript"></script> <script src="/resource/js/components/nav_builder.js" type="text/javascript"></script> <script src="/resource/js/components/floating_nav.js" type="text/javascript"></script> <div id="figure-lightbox-container"></div> <script id="figure-lightbox-template" type="text/template"> <div id="figure-lightbox" class="reveal-modal full" data-reveal aria-hidden="true" role="dialog"> <div class="lb-header"> <h1 id="lb-title"><%= articleTitle %></h1> <div id="lb-authors"> <span>Alhelí Calderón-Villarreal</span> <span>Lourdes Johanna Avelar Portillo</span> <a class="more-authors" href="/plosone/article/authors?id=10.1371/journal.pone.0303378">...</a> <span>Georgia L. Kayser</span> </div> <div class="lb-close" title="close"> </div> </div> <div class="img-container"> <div class="loader"> <i class="fa-spinner"></i> </div> <img class="main-lightbox-image" src=""/> <aside id="figures-list"> <% figureList.each(function (ix, figure) { %> <div class="change-img" data-doi="<%= figure.getAttribute('data-doi') %>"> <img class="aside-figure" src="/plosone/article/figure/image?size=inline&id=<%= figure.getAttribute('data-doi') %>" /> </div> <% }) %> <div class="dummy-figure"> </div> </aside> </div> <div id="lightbox-footer"> <div id="btns-container" class="lightbox-row <% if(figureList.length <= 1) { print('one-figure-only') } %>"> <div class="fig-btns-container reset-zoom-wrapper left"> <span class="fig-btn reset-zoom-btn">Reset zoom</span> </div> <div class="zoom-slider-container"> <div class="range-slider-container"> <span id="lb-zoom-min"></span> <div class="range-slider round" data-slider data-options="start: 20; end: 200; initial: 20;"> <span class="range-slider-handle" role="slider" tabindex="0"></span> <span class="range-slider-active-segment"></span> <input type="hidden"> </div> <span id="lb-zoom-max"></span> </div> </div> <% if(figureList.length > 1) { %> <div class="fig-btns-container"> <span class="fig-btn all-fig-btn"><i class="icon icon-all"></i> All Figures</span> <span class="fig-btn next-fig-btn"><i class="icon icon-next"></i> Next</span> <span class="fig-btn prev-fig-btn"><i class="icon icon-prev"></i> Previous</span> </div> <% } %> </div> <div id="image-context"> </div> </div> </div> </script> <script id="image-context-template" type="text/template"> <div class="footer-text"> <div id="figure-description-wrapper"> <div id="view-more-wrapper" style="<% descriptionExpanded? print('display:none;') : '' %>"> <span id="figure-title"><%= title %></span> <p id="figure-description"> <%= description %>   </p> <span id="view-more">show more<i class="icon-arrow-right"></i></span> </div> <div id="view-less-wrapper" style="<% descriptionExpanded? print('display:inline-block;') : '' %>" > <span id="figure-title"><%= title %></span> <p id="full-figure-description"> <%= description %>   <span id="view-less">show less<i class="icon-arrow-left"></i></span> </p> </div> </div> </div> <div id="show-context-container"> <a class="btn show-context" href="<%= showInContext(strippedDoi) %>">Show in Context</a> </div> <div id="download-buttons"> <h3>Download:</h3> <div class="item"> <a href="/plosone/article/figure/image?size=original&download=&id=<%= doi %>" title="original image"> <span class="download-btn">TIFF</span> </a> <span class="file-size"><%= fileSizes.original %></span> </div> <div class="item"> <a href="/plosone/article/figure/image?size=large&download=&id=<%= doi %>" title="large image"> <span class="download-btn">PNG</span> </a> <span class="file-size"><%= fileSizes.large %></span> </div> <div class="item"> <a href="/plosone/article/figure/powerpoint?id=<%= doi %>" title="PowerPoint slide"> <span class="download-btn">PPT</span> </a> </div> </div> </script> <div class="article-content"> <div id="figure-carousel-section"> <h2>Figures</h2> <div id="figure-carousel"> <div class="carousel-wrapper"> <div class="slider"> <div class="carousel-item lightbox-figure" data-doi="10.1371/journal.pone.0303378.t001"> <img src="/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t001" loading="lazy" alt="Table 1" /> </div> <div class="carousel-item lightbox-figure" data-doi="10.1371/journal.pone.0303378.t002"> <img src="/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t002" loading="lazy" alt="Table 2" /> </div> <div class="carousel-item lightbox-figure" data-doi="10.1371/journal.pone.0303378.g001"> <img src="/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0303378.g001" loading="lazy" alt="Fig 1" /> </div> <div class="carousel-item lightbox-figure" data-doi="10.1371/journal.pone.0303378.g002"> <img src="/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0303378.g002" loading="lazy" alt="Fig 2" /> </div> <div class="carousel-item lightbox-figure" data-doi="10.1371/journal.pone.0303378.t003"> <img src="/plosone/article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t003" loading="lazy" alt="Table 3" /> </div> </div> </div> <div class="carousel-control"> <span class="button previous"></span> <span class="button next"></span> </div> <div class="carousel-page-buttons"> </div> </div> </div> <script src="/resource/js/vendor/jquery.touchswipe.js" type="text/javascript"></script> <script src="/resource/js/components/figure_carousel.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery.dotdotdot.js" type="text/javascript"></script> <div class="article-text" id="artText"> <div xmlns:plos="http://plos.org" class="abstract toc-section abstract-type-"><a id="abstract0" name="abstract0" data-toc="abstract0" class="link-target" title="Abstract"></a><h2>Abstract</h2><div class="abstract-content"> <div id="section1" class="section toc-section"><a id="sec001" name="sec001" class="link-target" title="Background"></a> <h3>Background</h3> <a id="article1.front1.article-meta1.abstract1.sec1.p1" name="article1.front1.article-meta1.abstract1.sec1.p1" class="link-target"></a><p>Domains of adequate menstrual health (MH) include access to water, sanitation, and hygiene (WASH). People who menstruate with social disadvantages—such as homelessness or drug injection practices–often face barriers to WASH access. However, validated instruments to measure MH are limited among marginalized populations, and available instruments involve lengthy surveys. We developed and evaluated psychometric properties of a novel ‘<em>MH WASH Domain Scale-12</em>’ among people who menstruate and who inject drugs in the Tijuana–San Diego region and identified correlates of MH access using this scale.</p> </div> <div id="section2" class="section toc-section"><a id="sec002" name="sec002" class="link-target" title="Methods"></a> <h3>Methods</h3> <a id="article1.front1.article-meta1.abstract1.sec2.p1" name="article1.front1.article-meta1.abstract1.sec2.p1" class="link-target"></a><p>We constructed a MH-scale based on access to twelve WASH-related items: (1) menstrual products, (2) body hygiene (bathing per week), (3) water sources for bathing, (4) improved, (5) non-shared, (6) available, (7) private, (8) nearby, (9) and safe sanitation facilities, (10) availability of soap, (11) water source for handwashing, and (12) handwashing facilities with soap/water. Variables were dichotomized and summed, with scores ranging from 0–12 points and higher scores indicating better MH access. We assessed the scale’s reliability and construct and content validity using data from a binational cross-sectional study. The sample included people who inject drugs (PWID) who had ever menstruated in their lifetime and were 18+ during 2020–2021. MH-WASH items were described, and the scale was further used as an outcome variable to identify correlates.</p> </div> <div id="section3" class="section toc-section"><a id="sec003" name="sec003" class="link-target" title="Results"></a> <h3>Results</h3> <a id="article1.front1.article-meta1.abstract1.sec3.p1" name="article1.front1.article-meta1.abstract1.sec3.p1" class="link-target"></a><p>Among 125 (124 cis-female and 1 trans-male) PWID that reported menstruating, our ‘<em>MH WASH Domain Scale-12’</em> was reliable (Cronbach’s alpha = 0.81, McDonald’s Omega total = 0.83) and valid. We identified two sub-domains: Factor-1 included items describing ‘WASH availability’ and Factor-2 contained items related to ‘WASH security’—encompassing physical and biological safety. Scale scores were significantly lower among participants experiencing unsheltered homelessness compared to participants experiencing sheltered homelessness or living in permanent housing.</p> </div> <div id="section4" class="section toc-section"><a id="sec004" name="sec004" class="link-target" title="Conclusion"></a> <h3>Conclusion</h3> <a id="article1.front1.article-meta1.abstract1.sec4.p1" name="article1.front1.article-meta1.abstract1.sec4.p1" class="link-target"></a><p>We constructed and validated a novel and reliable scale to measure MH-related WASH access that can be used to assess MH among marginalized populations in English- and Spanish-speaking contexts. Using this scale we identified disparities in MH-WASH access among PWID and who menstruate in the US-Mexico border region.</p> </div> </div></div> <div xmlns:plos="http://plos.org" class="articleinfo"><p><strong>Citation: </strong>Calderón-Villarreal A, Avelar Portillo LJ, Abramovitz D, Goldenberg S, Flanigan S, Quintana PJE, et al. (2024) A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs. PLoS ONE 19(5): e0303378. https://doi.org/10.1371/journal.pone.0303378</p><p><strong>Editor: </strong>Kimberly Page, University of New Mexico Health Sciences Center, UNITED STATES</p><p><strong>Received: </strong>August 17, 2023; <strong>Accepted: </strong>April 23, 2024; <strong>Published: </strong> May 10, 2024</p><p><strong>Copyright: </strong> © 2024 Calderón-Villarreal et al. This is an open access article distributed under the terms of the <a href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</a>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p><p><strong>Data Availability: </strong>All relevant data are within the manuscript and its <a href="#sec019">Supporting Information</a> files, including all raw data required to replicate the results of our study.</p><p><strong>Funding: </strong>The La Frontera cohort study was funded by the National Institute of Drug Abuse (NIDA) grant number R01DA049644 (PI: SAS). ACV received a NIDA Diversity Supplement grant number 3R01DA049644-03S2 linked to the aforementioned parent grant, and a Scholarship for Doctoral Studies Abroad from the National Council of Science and Technology (CONACYT) 2020 in Mexico, as part of the University of California Institute for Mexico and the US (UC-MEXUS) Alliance. Funding was also provided to LJAP by the Fogarty International Center of the National Institutes of Health under award number D43TW009343 and the University of California Global Health Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or UCGHI. Funding was also provided by the National Institute of Environmental Health Sciences (NIEHS) grant number K01ES031697 to GLK. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</p><p><strong>Competing interests: </strong> The authors have declared that no competing interests exist.</p></div> <div xmlns:plos="http://plos.org" id="section1" class="section toc-section"><a id="sec005" name="sec005" data-toc="sec005" class="link-target" title="Introduction"></a><h2>Introduction</h2><a id="article1.body1.sec1.p1" name="article1.body1.sec1.p1" class="link-target"></a><p>One important domain of menstrual health is body care–which requires access to water, sanitation, and hygiene (WASH). Menstrual health (MH) was defined in 2021 by the Global Menstrual Collective as “a state of complete physical, mental, and social well-being and not merely the absence of disease, in relation to the menstrual cycle” [<a href="#pone.0303378.ref001" class="ref-tip">1</a>]. Achieving MH is based on a multi-domains construct that implies women, girls, and all people who menstruate have access to ‘information’, ‘health care’, ‘an environment free of stigma’, ‘participation in all spheres of life’, and ‘WASH facilities and services’ [<a href="#pone.0303378.ref001" class="ref-tip">1</a>]. The WASH domain, also known as the ‘body care’ domain of MH, was defined for menstruating individuals as “care for their bodies during menstruation such that their preferences, hygiene, comfort, privacy, and safety are supported” [<a href="#pone.0303378.ref001" class="ref-tip">1</a>]. This includes access to menstrual materials and private and safe facilities for changing, washing their body and hands (e.g., handwashing facilities with water and soap), and cleaning and/or disposing of used materials [<a href="#pone.0303378.ref001" class="ref-tip">1</a>]. Of note, the WASH domain of MH is not referred to as ‘menstrual hygiene’, a term that has been argued to simplify and stigmatize menstruation as something unclean, but as a comprehensive approach of important elements for ‘caring for one’s body’ during menstruation—which is only one of the five main domains of MH [<a href="#pone.0303378.ref001" class="ref-tip">1</a>,<a href="#pone.0303378.ref002" class="ref-tip">2</a>].</p> <a id="article1.body1.sec1.p2" name="article1.body1.sec1.p2" class="link-target"></a><p>PWID are a vulnerable group because of drug use, criminalization, many experience homelessness and many engage in sex work. Women, girls, trans-man and non-binary people who menstruate and who are engaged in substance use face barriers to access sexual and reproductive health and MH-WASH services [<a href="#pone.0303378.ref003" class="ref-tip">3</a>–<a href="#pone.0303378.ref006" class="ref-tip">6</a>]. Few studies have explored MH among PWID who menstruate and particularly few in the Tijuana-San Diego region [<a href="#pone.0303378.ref005" class="ref-tip">5</a>,<a href="#pone.0303378.ref007" class="ref-tip">7</a>]. Menstruation has been identified as an extra challenge among women who inject drugs and who experience homelessness [<a href="#pone.0303378.ref007" class="ref-tip">7</a>]. In order to access MH, women who inject drugs and experience homelessness prioritize access to private and safe WASH facilities, menstrual products and washing their bodies more often [<a href="#pone.0303378.ref007" class="ref-tip">7</a>]. Lack of private facilities can impact MH access among PWID experiencing homelessness [<a href="#pone.0303378.ref005" class="ref-tip">5</a>]. Moreover, lack of MH-WASH services among PWID are often exacerbated by stigma, violence, and police victimization. Among women who inject drugs, unmet MH needs had been associated with self-isolation and feeling “disgusting” and “nasty”, and stigma is commonly reported during menstruation, limiting women’s access to facilities and resources [<a href="#pone.0303378.ref007" class="ref-tip">7</a>]. Additionally, people with intersecting vulnerabilities such as those experiencing homelessness, people engaged in sex work, those living with socioeconomic/geographic disadvantages, and mobile populations often face additional challenges accessing those services which have been barely addressed with current MH scales [<a href="#pone.0303378.ref001" class="ref-tip">1</a>,<a href="#pone.0303378.ref003" class="ref-tip">3</a>,<a href="#pone.0303378.ref008" class="ref-tip">8</a>,<a href="#pone.0303378.ref009" class="ref-tip">9</a>].</p> <a id="article1.body1.sec1.p3" name="article1.body1.sec1.p3" class="link-target"></a><p>To accurately track MH, the development and validation of novel measurements are needed to characterize and address the unmet needs of marginalized populations [<a href="#pone.0303378.ref010" class="ref-tip">10</a>,<a href="#pone.0303378.ref011" class="ref-tip">11</a>]. There are currently inconsistencies between definitions and operationalization of indicators used to measure MH needs, including the WASH domain of MH [<a href="#pone.0303378.ref010" class="ref-tip">10</a>]. Access to menstrual management products is not enough to achieve menstrual health [<a href="#pone.0303378.ref012" class="ref-tip">12</a>], and WASH services need be included when measuring MH access [<a href="#pone.0303378.ref011" class="ref-tip">11</a>]. Few instruments that measure MH domains are currently available. One of the most important measurement schemata of MH developed to date was produced by the Joint Monitoring Programme (JMP) for Water Supply, Sanitation and Hygiene by the United Nations International Children’s Emergency Fund (UNICEF) and the World Health Organization (WHO). The JMP instrument considers educational and cultural components and a single aspect of WASH services (having water and soap available) [<a href="#pone.0303378.ref013" class="ref-tip">13</a>]. However, the JMP also monitors WASH access in a separate component with lengthy questionnaires (100+ variables). Hennegan et al developed a comprehensive instrument to assess menstrual practice needs, including some WASH elements in 2020 [<a href="#pone.0303378.ref014" class="ref-tip">14</a>]. This instrument included items to describe how comfortable or clean adults and adolescents feel managing their menstruation, and covered key WASH variables [<a href="#pone.0303378.ref014" class="ref-tip">14</a>,<a href="#pone.0303378.ref015" class="ref-tip">15</a>]. In 2023, Hennegan et al described an indicator shortlist to monitor girl’s MH and hygiene, including indicators focused on menstrual material access, stigma, health care and WASH services at school [<a href="#pone.0303378.ref016" class="ref-tip">16</a>]. Although this instrument and instrument shortlist is useful for understanding women’s and girls’ needs in household and school contexts, it may not be suitable for marginalized populations if the duration of the survey application is long or focused on the household or school, particularly among unhoused or mobile populations for whom short surveys are more useful. To date, no instruments or brief scales have been developed for PWID, people experiencing homelessness, or mobile populations who menstruate or tested among these populations.</p> <a id="article1.body1.sec1.p4" name="article1.body1.sec1.p4" class="link-target"></a><p>There is limited knowledge of MH among PWID and a need for novel measures that assess MH among marginalized population. The aim of this study was to develop and provide preliminary validation of a measure of the WASH domain of MH and to apply the scale to identify sociodemographic characteristics that are related to the MH-WASH access among people who menstruate and who inject drugs in the Tijuana–San Diego metropolitan area.</p> </div> <div xmlns:plos="http://plos.org" id="section2" class="section toc-section"><a id="sec006" name="sec006" data-toc="sec006" class="link-target" title="Methods"></a><h2>Methods</h2> <div id="section1" class="section toc-section"><a id="sec007" name="sec007" class="link-target" title="Dataset"></a> <h3>Dataset</h3> <a id="article1.body1.sec2.sec1.p1" name="article1.body1.sec2.sec1.p1" class="link-target"></a><p>Data used for this cross-sectional analysis was collected at a single study visit during 2020–2021 from participants enrolled in a prospective <em>La Frontera</em> cohort study of PWID who live in the binational metropolitan area of Tijuana, Baja California, Mexico and San Diego, California, United States (US). This study received ethics approval from the institutional review boards at UCSD in La Jolla, California (IRB #191390) and Xochicalco University in Tijuana, Mexico. Participants provided written informed consent. Monetary incentives (total of $45 USD per individual) were provided to participants who were enrolled in the study and completed the screening and supplemental visit (administered approximately one week after the baseline visit) visits. Recruitment period started on 10/28/2020 and ended on 10/25/2021.</p> <a id="article1.body1.sec2.sec1.p2" name="article1.body1.sec2.sec1.p2" class="link-target"></a><p>The <em>La Frontera</em> cohort study used nonprobability sampling to identify individuals who reported injecting drugs within the last month (as evidenced through injection stigmata) and reported living in Tijuana or San Diego. Due to the main objective of the parent student, we enrolled participants residing in San Diego who reported having crossed the border to inject drugs in Tijuana within the last two years as well as those from either city who reported not having used illicit drugs on the other side of the border. Eligibility criteria for the parent study included individuals aged ≥ 18 or older who reported injecting drugs within the last month (verified by inspecting injection stigmata), living in Tijuana or San Diego between 2020 and 2021 [<a href="#pone.0303378.ref017" class="ref-tip">17</a>]. Among the 612 participants enrolled in <em>La Frontera</em> cohort study participants who reported they had ever menstruated in their lifetime and completed the WASH component questionnaire were included in this analysis, and we excluded 24 participants who reported never having menstruated (primary amenorrhea).</p> <a id="article1.body1.sec2.sec1.p3" name="article1.body1.sec2.sec1.p3" class="link-target"></a><p>Data were collected using street outreach and mobile vans in Tijuana and San Diego and surveys were administered by trained, bilingual interviewers who were residents of either city, as previously described in Strathdee et al., 2021 [<a href="#pone.0303378.ref017" class="ref-tip">17</a>]. The survey components included in this analysis are sociodemographic characteristics and MH-WASH variables. Sociodemographic characteristics included city of residence, gender identity, age, hours spent outside, housing status, and sex work status.</p> </div> <div id="section2" class="section toc-section"><a id="sec008" name="sec008" class="link-target" title="Descriptive statistics"></a> <h3>Descriptive statistics</h3> <a id="article1.body1.sec2.sec2.p1" name="article1.body1.sec2.sec2.p1" class="link-target"></a><p>We described general characteristics of the participants, including sociodemographic, MH-WASH variables, and menstrual status. We explored MH-WASH by sociodemographic characteristics and described MH-WASH access gaps between population subgroups based on chi squared (X<sup>2</sup>) significance testing. Menstrual status was classified into three categories: based on each participants’ last date of menstruation, and was classified as follows: menstruating, of reproductive age with amenorrhea (i.e., not menstruating), and menopause (age greater than 49-years-old without menstrual cycles). Menstruating status was based on self-reporting having menstruation in the past 12 months. Socioeconomic variables were utilized to describe the population, validate the scale, and identify correlates. These variables included city of residence, gender identity, age, hours spent outside (on the streets), housing status, and sex work status. Age was a continuous variable. City of residence included San Diego and Tijuana. Gender identity included women and one trans man as we only studied people who had ever menstruated. Sex work in the last six months was a dichotomous variable, based on whether or not the study participant reported ‘prostitution or sex work’ as one of their sources of income during the specified time period. Housing status was classified into three categories: permanent housing, sheltered homelessness and unsheltered homelessness, as defined by the US Department of Housing and Urban Development [<a href="#pone.0303378.ref018" class="ref-tip">18</a>,<a href="#pone.0303378.ref019" class="ref-tip">19</a>]. In this study, housing status was defined as the main place where a participant slept in the last six months. Permanent housing included participants who reported sleeping in a house or apartment owned or rented by participants’ parents, themselves, their spouse/sexual partner, family, or friends. Sheltered homelessness status included a participant reported having slept in a migrant worker camp, asylum shelter, shelter/welfare residence, workplace, short-term rented room (hotel, motel, or other rooming house), deportee shelter/camp, correctional institution (jail, prison, detention center), drug treatment center, medical care facility (i.e., hospital, hospice, or nursing home), or rented garage. Unsheltered homelessness status was categorized as participants who slept in a car, bus, truck, or other vehicle, abandoned building, on the streets, beach, parks, canal, woods, and shooting gallery in the last six months.</p> </div> <div id="section3" class="section toc-section"><a id="sec009" name="sec009" class="link-target" title="The ‘MH WASH Domain Scale-12’"></a> <h3>The ‘MH WASH Domain Scale-12’</h3> <a id="article1.body1.sec2.sec3.p1" name="article1.body1.sec2.sec3.p1" class="link-target"></a><p>The constructed <em>‘MH WASH Domain Scale-12’</em> contained MH access related items from a list of 22 WASH variables, including use and access to WASH services and MH materials. To develop the scale, we first explored pairwise correlations to select the items with positive or neutral correlations using Kendall’s correlation. The items included menstrual products used during the last period; sanitation (toilet) facilities that were improved, non-shared, available, private, nearby, and safe; having more than four showers/baths in the last week; improved water sources for bathing; and available soap (for any use), water sources for handwashing, and handwashing facilities with soap and water (<a href="#pone-0303378-t001">Table 1</a>). MH products access included reusable and disposable sanitary pads, tampons, and menstrual cups. Water sources and toilet facilities items referred to the main source/facility used in the past six months and were categorized as improved based on the JMP definitions [<a href="#pone.0303378.ref013" class="ref-tip">13</a>]. Improved water sources for showering/bathing included private and public tap water, protected well and spring, rainwater, delivered water, and packaged water. Improved toilet facilities include flush or pour flush toilet, pit latrine with slab, and composting toilet. A non-shared toilet refers to a toilet that was not shared with other households or with the general public. Sanitation privacy was defined as the frequency participants used toilets that were private (i.e., with a functioning door and lock) and classified as ‘always/usually available’ vs. ‘sometimes/rarely/never’. Nearby toilet was defined as a toilet facility accessible within 10 minutes or less walking distance based on the average distance walked in the sampled population. A safe sanitation facility was defined by the participants as not having experienced any physical, sexual, or verbal assault, robbery, arrest, or other form of harassment and violence while using the toilet. Availability of services/facilities was defined as ‘always or usually’ available. All variables were dichotomized because not all the individual variables had the same unit of measurement in the survey, where ‘1’ corresponds to an affirmative response (representing access), and 0 to a negative response (representing no or limited access).</p> <a class="link-target" id="pone-0303378-t001" name="pone-0303378-t001"></a><div class="figure" data-doi="10.1371/journal.pone.0303378.t001"><div class="img-box"><a title="Click for larger image" href="article/figure/image?size=medium&id=10.1371/journal.pone.0303378.t001" data-doi="10.1371/journal.pone.0303378" data-uri="10.1371/journal.pone.0303378.t001"><img src="article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t001" alt="thumbnail" class="thumbnail" loading="lazy"></a><div class="expand"></div></div><div class="figure-inline-download"> Download: <ul><li><a href="article/figure/powerpoint?id=10.1371/journal.pone.0303378.t001"><div class="definition-label">PPT</div><div class="definition-description">PowerPoint slide</div></a></li><li><a href="article/figure/image?download&size=large&id=10.1371/journal.pone.0303378.t001"><div class="definition-label">PNG</div><div class="definition-description">larger image</div></a></li><li><a href="article/figure/image?download&size=original&id=10.1371/journal.pone.0303378.t001"><div class="definition-label">TIFF</div><div class="definition-description">original image</div></a></li></ul></div><div class="figcaption"><span>Table 1. </span> Items included in the ’<em>Menstrual Health WASH Domain Scale-12</em>’.</div><p class="caption_target"></p><p class="caption_object"><a href="https://doi.org/10.1371/journal.pone.0303378.t001"> https://doi.org/10.1371/journal.pone.0303378.t001</a></p></div><a id="article1.body1.sec2.sec3.p2" name="article1.body1.sec2.sec3.p2" class="link-target"></a><p>To validate the <em>‘MH WASH Domain Scale-12’</em>, we required well-defined domains (i.e., smaller conceptual pieces feeding the construct) [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. To define these domains, we assessed the degree to which the selected items were good measures of the construct. To assess the degree to which these items measured what they were supposed to measure, we conducted a parallel analysis and an exploratory factor analysis. Based on the variance (h2) and correlations per each item we defined the best number of domains to organize the construct. The items with the most variability were included in the MH-WASH scale.</p> </div> <div id="section4" class="section toc-section"><a id="sec010" name="sec010" class="link-target" title="Validity and reliability of the ‘MH WASH Domain Scale-12’"></a> <h3>Validity and reliability of the ‘MH WASH Domain Scale-12’</h3> <a id="article1.body1.sec2.sec4.p1" name="article1.body1.sec2.sec4.p1" class="link-target"></a><p>To validate the scale, we performed validity and reliability assessments to test if the scale was accurately measuring the defined domain and how well it performed [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. First, to assess the validity of the scale, we tested if the scale was indeed measuring the WASH domain of MH. We conducted two validity tests: content and construct. Content validity assessed if the items adequately measured the domain of interests [<a href="#pone.0303378.ref021" class="ref-tip">21</a>]. Content validity (i.e., theoretical analysis) was tested in four stages: 1) defined theoretically the items and domains based on a literature review, 2) conducted a parallel analysis and exploratory factor analysis, 3) explored the relationship between each item in the construct and in the novel two-factor grouping, and 4) theoretically redefined the novel factor distribution (domains) [<a href="#pone.0303378.ref020" class="ref-tip">20</a>,<a href="#pone.0303378.ref021" class="ref-tip">21</a>].</p> <a id="article1.body1.sec2.sec4.p2" name="article1.body1.sec2.sec4.p2" class="link-target"></a><p>To evaluate the theoretical relationship of the scale with other constructs, we conducted construct validity testing [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. Construct validity testing assess the correlation of the scale and its domains/sub-scales with other variables [<a href="#pone.0303378.ref021" class="ref-tip">21</a>–<a href="#pone.0303378.ref023" class="ref-tip">23</a>]. Construct validity was tested using Kendall’s correlations. The sub-scales demonstrated covariation with other variables in accordance with the type of relationship we expected from the theoretical framework [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. We selected constructs/variables not used in the scale to explore positive, negative and neutral associations [<a href="#pone.0303378.ref021" class="ref-tip">21</a>]. Three variables were used to construct validity in our scale: ‘toilet functionality’, ‘hours spent outside’ (on the streets), and ‘age’. It is assumed that our scale items were positively correlated to other WASH items (not used in these scales), such as ‘toilet functionality’, because based on the literature we know that ‘sanitation access’ and ‘water source access’ variables must be related with a functional toilet facility [<a href="#pone.0303378.ref024" class="ref-tip">24</a>,<a href="#pone.0303378.ref025" class="ref-tip">25</a>]. Also, ‘hours spent outside’ (on the street) was expected to decrease WASH access, which was negatively related to ‘housing status’; that means, women without formal housing spend more time outside and have less access to WASH facilities [<a href="#pone.0303378.ref026" class="ref-tip">26</a>]. Finally, ‘age’ in years and WASH access were not associated in the literature.</p> <a id="article1.body1.sec2.sec4.p3" name="article1.body1.sec2.sec4.p3" class="link-target"></a><p>Additionally, to assess the reliability of the scale, we evaluated the internal consistency (i.e., the degree to which the set of items in the scale co-vary, relative to their sum score). We divided all variations of the scale into the unique and shared variation and computed the proportion of total variation that was shared. This assessment used two metrics: Cronbach’s Alpha (α) and McDonald’s Omega total (ω). We estimated α, the most common (traditional) and generally agreed upon internal consistency test [<a href="#pone.0303378.ref021" class="ref-tip">21</a>]. However, α has four assumptions that limit their use: each scale item must contribute equally to the total score, the items of the scale should be normally distributed, there should be no correlations between the error of the items, and the scale should be unidimensional [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. To address α limitations, we used the coefficient ω, which was an estimate of the general factor saturation of a test, allowing for the use of smaller subdomains to organize items after accounting for the primary domain [<a href="#pone.0303378.ref020" class="ref-tip">20</a>]. The cutoff point was ≥ 0.80 for both reliability tests [<a href="#pone.0303378.ref021" class="ref-tip">21</a>]. We described the scale and sub-scales distribution and measures of central tendency: mean, median, and mode, with the corresponding measures of dispersion, standard deviation (SD) and interquartile range (IQR).</p> </div> <div id="section5" class="section toc-section"><a id="sec011" name="sec011" class="link-target" title="Sociodemographic variables and correlates of the ‘MH WASH Domain Scale-12’"></a> <h3>Sociodemographic variables and correlates of the ‘MH WASH Domain Scale-12’</h3> <a id="article1.body1.sec2.sec5.p1" name="article1.body1.sec2.sec5.p1" class="link-target"></a><p>We evaluated city of residence, sex work, and housing status as potential correlates of the <em>‘MH WASH Domain Scale-12’</em> score. Since the score was highly skewed to the left, to facilitate an appropriate inference method, we first converted the score into a 0–1 interval variable by dividing the scale score by 12, with the new variable essentially representing the proportion of score items to which a participant had access to. Then, this new variable was used as the outcome variable in a Beta regression model to evaluate its association with independent variables. We conducted univariate and multivariable regression analyses between the independent (sociodemographic variables) and dependent variables (scale score). We calculated unadjusted and adjusted risk ratios (RR, aRR) along with the corresponding 95% confidence intervals (CIs) using R version 4.0.2.</p> </div> </div> <div xmlns:plos="http://plos.org" id="section3" class="section toc-section"><a id="sec012" name="sec012" data-toc="sec012" class="link-target" title="Results"></a><h2>Results</h2> <div id="section1" class="section toc-section"><a id="sec013" name="sec013" class="link-target" title="Sample characteristics"></a> <h3>Sample characteristics</h3> <a id="article1.body1.sec3.sec1.p1" name="article1.body1.sec3.sec1.p1" class="link-target"></a><p>Of the 125 participants (124 cis-females and 1 trans-male) who reported they had ever menstruated in their lifetime; the average age was 42.7 (SD = 10.4). Sixty-one percent (n = 76) of participants lived in San Diego, and the remaining 39% (n = 49) lived in Tijuana. Among those included in this study, 42% reported experiencing unsheltered homelessness at least once in the last six months. In the study, 32% reported currently experiencing unsheltered homelessness, 30% reported experiencing sheltered homelessness, and 38% reported living in permanent housing (<a href="#pone-0303378-t002">Table 2</a>). Twenty-seven percent of participants reported sex work in the last six months. Of all participants who reported ever menstruating in their lifetime, 57% were menstruating (i.e., have had at least one menstruation in the last 12 months), 17% were of reproductive age without menstruation (i.e., secondary amenorrhea), and 26% were in menopause. Secondary amenorrhea was not experienced by any of the participants who reported sex work, but it was experienced by 23% of participants who did not report sex work (p = 0.005). The prevalence of secondary amenorrhea was 24% in San Diego residents and 6% among those living in Tijuana (p = 0.02).</p> <a class="link-target" id="pone-0303378-t002" name="pone-0303378-t002"></a><div class="figure" data-doi="10.1371/journal.pone.0303378.t002"><div class="img-box"><a title="Click for larger image" href="article/figure/image?size=medium&id=10.1371/journal.pone.0303378.t002" data-doi="10.1371/journal.pone.0303378" data-uri="10.1371/journal.pone.0303378.t002"><img src="article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t002" alt="thumbnail" class="thumbnail" loading="lazy"></a><div class="expand"></div></div><div class="figure-inline-download"> Download: <ul><li><a href="article/figure/powerpoint?id=10.1371/journal.pone.0303378.t002"><div class="definition-label">PPT</div><div class="definition-description">PowerPoint slide</div></a></li><li><a href="article/figure/image?download&size=large&id=10.1371/journal.pone.0303378.t002"><div class="definition-label">PNG</div><div class="definition-description">larger image</div></a></li><li><a href="article/figure/image?download&size=original&id=10.1371/journal.pone.0303378.t002"><div class="definition-label">TIFF</div><div class="definition-description">original image</div></a></li></ul></div><div class="figcaption"><span>Table 2. </span> Sociodemographic and WASH characteristics of 125 PWID and who have menstruated participants in the Tijuana-San Diego metropolitan area in 2020–2021.</div><p class="caption_target"></p><p class="caption_object"><a href="https://doi.org/10.1371/journal.pone.0303378.t002"> https://doi.org/10.1371/journal.pone.0303378.t002</a></p></div></div> <div id="section2" class="section toc-section"><a id="sec014" name="sec014" class="link-target" title="MH-WASH characteristics"></a> <h3>MH-WASH characteristics</h3> <a id="article1.body1.sec3.sec2.p1" name="article1.body1.sec3.sec2.p1" class="link-target"></a><p>In this study, we also examine variables that capture the WASH domain of MH. In our sampled population, 15% of participants reported lacking access to menstrual products during their last period, 38% reported showering less than five times in the last week, and 2% reported water lacking or using unimproved/surface water as their main water source for bathing. Fifteen percent of participants reported no access to water sources to practice daily handwashing, 30% had no handwashing facilities with soap and water available all the time, and 25% had no soap always/usually available for any use. In terms of sanitation access, 10% of participants did not have access to toilet facilities, 29% relied on sanitation facilities that were not private (with a working lock and door), 18% that were not improved, and 14% reported walking over 10 minutes to reach a toilet facility. Furthermore, 16% of participants experienced violence or harassment using a toilet. Among those individuals who reported experiencing violence while using a toilet (N = 20), the most common types of violence were verbal (75%) and physical assault (40%) (<a href="#pone-0303378-t002">Table 2</a>).</p> <a id="article1.body1.sec3.sec2.p2" name="article1.body1.sec3.sec2.p2" class="link-target"></a><p>Most of the MH-WASH access indicators varied by housing status. A higher proportion of participants experiencing unsheltered homelessness shared their main toilet facility (83%) in comparison to those individuals experiencing sheltered homelessness (49%) and those who lived in permanent housing (45%, X<sup>2</sup> p<0.001). Two-thirds (65%) of people experiencing unsheltered homelessness used a public toilet as their main toilet facility (sharing it with the general public), whereas only 16% of participants experiencing sheltered homelessness and 13% of those living in permanent housing did so (p<0.001). Only half (53%) of participants experiencing unsheltered homelessness had access to toilet facilities that had privacy, whereas individuals experiencing sheltered homelessness and those living in permanent housing had 76% and 85% access, respectively (p<0.001). Similarly, access to improved toilet facilities was lower (65%) among individuals experiencing unsheltered homelessness than among sheltered participants (86%) and those living in permanent housing (94%, p<0.001). Only 43% of participants experiencing unsheltered homelessness had access to more than four showers per week, while more than 70% of the participants that reported experiencing sheltered homelessness and 74% of permanently housed participants had the corresponding access (p = 0.007). Availability of handwashing facilities with soap and water was lower among participants experiencing homelessness (p = 0.023), particularly among those experiencing sheltered homelessness (unsheltered = 65%, sheltered = 57%), in comparison with those living in permanent housing (85%). We also found a social gradient by housing status for availability of soap, as those participants experiencing unsheltered homelessness (65%) and sheltered homelessness (70%) had lower access to soap (for any use) than those living in permanent housing (89%) (p = 0.037). We found that harassment or violence experienced while using toilet facilities had a social gradient based on housing status, with only 9% of participants living in permanent housing reporting ever experiencing harassment or violence while using the toilet, compared to 14% of those experiencing sheltered homelessness and 28% of those experiencing unsheltered homelessness (p = 0.045). Among sheltered and unsheltered homeless individuals who had experienced violence, verbal assault was the most common type (sheltered = 80%, unsheltered = 64%), followed by physical assault (sheltered = 40%, unsheltered = 36%).</p> <a id="article1.body1.sec3.sec2.p3" name="article1.body1.sec3.sec2.p3" class="link-target"></a><p>We also found that MH-WASH needs differed significantly by sociodemographic variables. PWID living in Tijuana had lower access to menstrual products compared to those living in San Diego (71% vs 93%, respectively p = 0.002) and lower access to available handwashing facilities with soap and water (Tijuana: 55% vs San Diego: 79%, p = 0.009). Participants who reported sex work in the last six months had lower access to available water for handwashing (71% vs 90%, p = 0.015) and to handwashing facilities with soap and water (50% vs 77%, p = 0.007), as compared to those who did not report sex work.</p> </div> <div id="section3" class="section toc-section"><a id="sec015" name="sec015" class="link-target" title="The ‘MH WASH Domain Scale-12’"></a> <h3>The ‘MH WASH Domain Scale-12’</h3> <a id="article1.body1.sec3.sec3.p1" name="article1.body1.sec3.sec3.p1" class="link-target"></a><p>For the construction of the ‘<em>MH WASH Domain Scale-12’</em>, twelve items with mainly positive or neutral correlations were included. We identified that using two-factors (referred to as F1 and F2) best organized the construct (<a href="#pone.0303378.s001">S1 Table</a>) based on parallel and factor analyses. The identified factors corresponded to two sub-domains. Factor-1 (F1) included five items (water for handwashing available, soap available for any use, handwashing facility with water and soap available, main toilet available, and menstrual products) broadly related to the availability of WASH sources, and consequently we defined it as the <em>‘WASH Availability’</em> sub-scale (<a href="#pone-0303378-g001">Fig 1</a>). Factor-2 (F2) contained seven items related to <em>‘WASH Security’</em>—encompassing physical and biological safety—including improved water sources for bathing, and access to improved, nearby (<10 min walking), non-shared, private, and safe toilet facilities. These sub-scale items contained two areas: a) the security of the water used (for bathing) as defined by appropriateness for human consumption or use without health risk and b) physical security accessing sanitation facilities. In sum, this process resulted in two sub-scales: ‘<em>WASH availability</em>’ and ‘<em>WASH security</em>’.</p> <a class="link-target" id="pone-0303378-g001" name="pone-0303378-g001"></a><div class="figure" data-doi="10.1371/journal.pone.0303378.g001"><div class="img-box"><a title="Click for larger image" href="article/figure/image?size=medium&id=10.1371/journal.pone.0303378.g001" data-doi="10.1371/journal.pone.0303378" data-uri="10.1371/journal.pone.0303378.g001"><img src="article/figure/image?size=inline&id=10.1371/journal.pone.0303378.g001" alt="thumbnail" class="thumbnail" loading="lazy"></a><div class="expand"></div></div><div class="figure-inline-download"> Download: <ul><li><a href="article/figure/powerpoint?id=10.1371/journal.pone.0303378.g001"><div class="definition-label">PPT</div><div class="definition-description">PowerPoint slide</div></a></li><li><a href="article/figure/image?download&size=large&id=10.1371/journal.pone.0303378.g001"><div class="definition-label">PNG</div><div class="definition-description">larger image</div></a></li><li><a href="article/figure/image?download&size=original&id=10.1371/journal.pone.0303378.g001"><div class="definition-label">TIFF</div><div class="definition-description">original image</div></a></li></ul></div><div class="figcaption"><span>Fig 1. </span> Factor analysis of the <em>‘Menstrual Health WASH Domain Scale-12’</em> items.</div><p class="caption_target"></p><p class="caption_object"><a href="https://doi.org/10.1371/journal.pone.0303378.g001"> https://doi.org/10.1371/journal.pone.0303378.g001</a></p></div><a id="article1.body1.sec3.sec3.p2" name="article1.body1.sec3.sec3.p2" class="link-target"></a><p>Correlations between sub-scales to ‘toilet functionality’ (F1 = 0.35, F2 = 0.24) were positive, which could be interpreted as both sub-scales being similarly correlated to ‘toilet functionality’. Both sub-scales were negatively correlated to ‘hours spent outside’ (F1 = -0.10, F2 = -0.35). However, the <em>WASH Security</em> sub-scale had a stronger correlation with the ‘hours spent outside’, which could be related to the lack of access to appropriate sanitation and bathing facilities outside a household. No correlations were found with respect to ‘age’ (F1 = 0.03, F2 = 0.05). These findings were in agreement with the assumptions taken from the theoretical framework.</p> <a id="article1.body1.sec3.sec3.p3" name="article1.body1.sec3.sec3.p3" class="link-target"></a><p>Among 125 participants that reported ever menstruating, our ‘<em>MH WASH Domain Scale-12’</em> was found reliable (α: 0.80, ω total: 0.83) and valid. Omega total’s reliability was more appropriate for our scale characteristics, yet both traditional (α) and alternative (ω) reliability methods showed consistent findings. The ‘<em>MH WASH Domain Scale-12’</em> score had a minimum value of 0 and a maximum value of 12, with a higher score indicating higher access to MH-WASH. The distribution of the score was skewed to the left, mostly because 59% of participants had a scale score of 10+ points (<a href="#pone-0303378-g002">Fig 2</a>). The score mean was 9.4 (SD = 2.6), a median of 10.0 (IQR = 7.7–11.0), and a mode of 11.0. The ‘WASH Availability’ sub-scale score had a minimum value of 0 and maximum of 5, score mean of 4.1 (SD = 1.4), median of 5 (IQR = 3–5), and mode of 5. The ‘WASH Security’ sub-scale score had a minimum value of 0 and maximum of 7, score mean of 5.3 (SD = 1.6), median of 6 (IQR = 4–7), and mode of 7.</p> <a class="link-target" id="pone-0303378-g002" name="pone-0303378-g002"></a><div class="figure" data-doi="10.1371/journal.pone.0303378.g002"><div class="img-box"><a title="Click for larger image" href="article/figure/image?size=medium&id=10.1371/journal.pone.0303378.g002" data-doi="10.1371/journal.pone.0303378" data-uri="10.1371/journal.pone.0303378.g002"><img src="article/figure/image?size=inline&id=10.1371/journal.pone.0303378.g002" alt="thumbnail" class="thumbnail" loading="lazy"></a><div class="expand"></div></div><div class="figure-inline-download"> Download: <ul><li><a href="article/figure/powerpoint?id=10.1371/journal.pone.0303378.g002"><div class="definition-label">PPT</div><div class="definition-description">PowerPoint slide</div></a></li><li><a href="article/figure/image?download&size=large&id=10.1371/journal.pone.0303378.g002"><div class="definition-label">PNG</div><div class="definition-description">larger image</div></a></li><li><a href="article/figure/image?download&size=original&id=10.1371/journal.pone.0303378.g002"><div class="definition-label">TIFF</div><div class="definition-description">original image</div></a></li></ul></div><div class="figcaption"><span>Fig 2. </span> <em>‘Menstrual Health WASH Domain Scale-12’</em> score distribution among 125 PWID and who have menstruated in Tijuana-San Diego metropolitan area.</div><p class="caption_target"></p><p class="caption_object"><a href="https://doi.org/10.1371/journal.pone.0303378.g002"> https://doi.org/10.1371/journal.pone.0303378.g002</a></p></div></div> <div id="section4" class="section toc-section"><a id="sec016" name="sec016" class="link-target" title="Correlates of the ‘MH WASH Domain Scale-12’"></a> <h3>Correlates of the ‘MH WASH Domain Scale-12’</h3> <a id="article1.body1.sec3.sec4.p1" name="article1.body1.sec3.sec4.p1" class="link-target"></a><p>The MH-WASH score was significantly associated with housing status (<a href="#pone-0303378-g002">Fig 2</a>). Participants living in permanent housing (aRR: 3.18, CI95%: 2.00, 5.04) as well as those experiencing sheltered homelessness (aRR: 2.76, 95%CI: 1.65, 4.63) had significantly higher access to MH-WASH as compared to participants experiencing unsheltered homelessness (<em>MH-WASH Domain-12</em> score: 10.2 [SD = 2.3], 9.4 [SD = 2.6], 8.2 [SD = 2.6] respectively) (<a href="#pone-0303378-t003">Table 3</a>). We found association by city of residence only after adjusting for covariates, San Diego residents had significantly higher access to MH-WASH (aRR: 1.61, CI95%: 1.03, 2.52) than those residing in Tijuana (Tijuana 8.9 [SD = 2.9], San Diego 9.6 [SD = 2.4]). No associations were found by sex work status. People who menstruate and who inject drugs had comparable MH-WASH access by reported sex work in the past six months (sex work 9.0 [SD = 2.7], no sex work 9.5 [SD = 2.5]).</p> <a class="link-target" id="pone-0303378-t003" name="pone-0303378-t003"></a><div class="figure" data-doi="10.1371/journal.pone.0303378.t003"><div class="img-box"><a title="Click for larger image" href="article/figure/image?size=medium&id=10.1371/journal.pone.0303378.t003" data-doi="10.1371/journal.pone.0303378" data-uri="10.1371/journal.pone.0303378.t003"><img src="article/figure/image?size=inline&id=10.1371/journal.pone.0303378.t003" alt="thumbnail" class="thumbnail" loading="lazy"></a><div class="expand"></div></div><div class="figure-inline-download"> Download: <ul><li><a href="article/figure/powerpoint?id=10.1371/journal.pone.0303378.t003"><div class="definition-label">PPT</div><div class="definition-description">PowerPoint slide</div></a></li><li><a href="article/figure/image?download&size=large&id=10.1371/journal.pone.0303378.t003"><div class="definition-label">PNG</div><div class="definition-description">larger image</div></a></li><li><a href="article/figure/image?download&size=original&id=10.1371/journal.pone.0303378.t003"><div class="definition-label">TIFF</div><div class="definition-description">original image</div></a></li></ul></div><div class="figcaption"><span>Table 3. </span> Correlates of the ’<em>Menstrual Health WASH Domain Scale-12</em>’ among 125 PWID and who have menstruated in Tijuana-San Diego metropolitan area.</div><p class="caption_target"></p><p class="caption_object"><a href="https://doi.org/10.1371/journal.pone.0303378.t003"> https://doi.org/10.1371/journal.pone.0303378.t003</a></p></div></div> </div> <div xmlns:plos="http://plos.org" id="section4" class="section toc-section"><a id="sec017" name="sec017" data-toc="sec017" class="link-target" title="Discussion"></a><h2>Discussion</h2><a id="article1.body1.sec4.p1" name="article1.body1.sec4.p1" class="link-target"></a><p>In this study, we report on reliability, validity, and correlates of a brief, novel scale to assess the WASH domain of MH among women who menstruate and who inject drugs, which was found to be both reliable and valid. We identified two sub-scales–<em>WASH availability</em> and <em>WASH security</em>–whose performance was assessed. Our scale complements the available ‘Menstrual Practices Questionnaire’ (MPQ) and ‘Menstrual Practices Needs Scale’ (MPNS-36) validated by Hennegan et al. (2020) in Uganda. The MPNS-36 and MPQ are longer and more detailed instruments including variables about perceptions of comfort, satisfaction, adequacy, worries and concerns during the last menstrual period, and about activities undertaken to collect, contain, and removed menstrual blood from the body [<a href="#pone.0303378.ref014" class="ref-tip">14</a>,<a href="#pone.0303378.ref015" class="ref-tip">15</a>]. These instruments are useful for women and girls, especially in households and school environments. Particularly for girls, the multi-dimensional ‘Menstrual Hygiene Management Scale’ (MHHM) validated in India is useful to explore behaviors related to preparation of clean absorbent, hygiene, and disposal in households and school environments [<a href="#pone.0303378.ref027" class="ref-tip">27</a>]. The available MH instruments focused on a variety of MH domains mainly in Asian and African contexts [<a href="#pone.0303378.ref014" class="ref-tip">14</a>,<a href="#pone.0303378.ref015" class="ref-tip">15</a>,<a href="#pone.0303378.ref027" class="ref-tip">27</a>]. Yet, limited literature has examined or measured MH and/or MH-WASH domain in the Americas region, and none in binational contexts.</p> <a id="article1.body1.sec4.p2" name="article1.body1.sec4.p2" class="link-target"></a><p>An important strength of this study is that this scale was based on the WHO/UNICEF JMP definitions for WASH. The JMP is the largest, nationally representative global effort for WASH monitoring, making our scale and its variables comparable and easy to adapt to populations from different contexts. The JMP also has an important MH instrument and others available to measure WASH. The JMP instrument for MH considers mainly educational and cultural components, and WASH indicators are explored in different contexts by extensive WASH questionnaires separately [<a href="#pone.0303378.ref013" class="ref-tip">13</a>]. Our scale provides a briefer alternative to explored WASH services linked with MH, with fewer items, which does not take long to administer and is easy to apply to other marginalized populations. Additionally, our scale includes variables not considered by the JMP, such as measuring WASH beyond the household unit of measurement, the time taken to access sanitation facilities and frequency of access to showers/baths to maintain body hygiene.</p> <a id="article1.body1.sec4.p3" name="article1.body1.sec4.p3" class="link-target"></a><p>WASH insecurity disproportionately affects women [<a href="#pone.0303378.ref028" class="ref-tip">28</a>,<a href="#pone.0303378.ref029" class="ref-tip">29</a>]. Women’s WASH needs are different than men due to biological differences such as menstruation and pregnancy [<a href="#pone.0303378.ref008" class="ref-tip">8</a>,<a href="#pone.0303378.ref030" class="ref-tip">30</a>]. Women’s access to WASH services, together with other MH related actions such as elimination of menstrual product taxes, menstrual education, and campaigns against stigma, are all important elements to promote gender equity [<a href="#pone.0303378.ref012" class="ref-tip">12</a>,<a href="#pone.0303378.ref028" class="ref-tip">28</a>,<a href="#pone.0303378.ref031" class="ref-tip">31</a>]. Assessments of MH-WASH access represent measurements of gendered WASH access that pertain to the Sustainable Development Goal targets 6.1 and 6.2 for WASH access among women and girls [<a href="#pone.0303378.ref028" class="ref-tip">28</a>]. Caruso et al and the JMP recently proposed 15 WASH indicators for enhanced monitoring of gender in WASH, some also relate to MH [<a href="#pone.0303378.ref028" class="ref-tip">28</a>]. The proposed 2023 sanitation and hygiene indicators included a clean, private and safe sanitation facility, not feeling unsafe at sanitation facilities due to fear of being harmed or assaulted, and access to sufficient menstrual materials and to a clean, private, and safe space during their last menstrual period, which are similar to four of the items included in our scale (sanitation facility that is private, non-shared and free of violence or harassment, and access to menstrual materials) [<a href="#pone.0303378.ref028" class="ref-tip">28</a>]. However, several of the aforementioned indicators for gender in WASH are based on the household level, limiting their use among people experiencing homelessness or housing insecurity. Further, this draft MH-WASH JMP indicators do not include time to sanitation, which is an important measure of access for sanitation that impact MH. Furthermore, our scale overlaps with the WASH gender equality measure (WASH-GEM) developed by Carrard et al, is also at the individual level, and our scale is compatible with its ‘resources’ domain [<a href="#pone.0303378.ref031" class="ref-tip">31</a>]. Yet, measures and indicators of gender in WASH, such as the WASH-GEM, explore a larger set of domains related to gender equity, and are beyond the MH objective of our study, but should be considered in future studies of MH among vulnerable populations.</p> <a id="article1.body1.sec4.p4" name="article1.body1.sec4.p4" class="link-target"></a><p>Our scale provides one of the few assessments of an important domain of MH access. The scale was validated among PWID and who reported ever menstruating. PWID represent a marginalized population underexplored by the WASH and MH fields, which often experience insecurity accessing basic services–including WASH [<a href="#pone.0303378.ref032" class="ref-tip">32</a>]. Marginalized populations often share common sources of structural oppression limiting their access to WASH services. We developed a scale that is not linked with substance use or housing characteristics but instead focuses on WASH insecurities experienced among PWID and how menstruate along the US-Mexico border region. The scale validated in this study can subsequently be validated and used among other populations to test the MH-WASH domain, which may be particularly useful among marginalized and mobile populations (e.g., unhoused, migrants, and refugees), PWID in other locations, trans men who inject drugs, and communities experiencing WASH insecurity. Furthermore, our scale is shorter than other available instruments, taking less time to measure and easy to be included in longer surveys, complementing the current set of available instruments to measure MH.</p> <a id="article1.body1.sec4.p5" name="article1.body1.sec4.p5" class="link-target"></a><p>The exploration of demographic variables expands our understanding of intersecting vulnerabilities affecting menstrual health access particularly among women who menstruate and who inject drugs. These findings complement Keiser et al.’s study on menstrual health needs among 62 women of reproductive age on treatment for substance use disorder in Virginia, that reported menstrual poverty in 81% of the participants [<a href="#pone.0303378.ref003" class="ref-tip">3</a>]. Scale scores were correlated with housing status. Access to a household or a shelter was significantly associated with higher scores on our ‘<em>MH WASH Domain Scale-12’</em>, highlighting the MH-WASH insecurity unsheltered women who menstruate and who inject drugs experience on a daily basis. Our results complement the studies conducted in Los Angeles and New York City (NYC) on menstruation and homelessness. Avelar Portillo et al.’s study among 79 women and 2 transgender men experiencing homelessness in Los Angeles, reported insecurity accessing MH-WASH services: 27% reported insecurity accessing >4 showers per week, while in our study 38% reported this challenge [<a href="#pone.0303378.ref006" class="ref-tip">6</a>]. Gruer et al.’s (2021) study among individuals experiencing homelessness in NYC, reported that people experiencing sheltered and unsheltered homelessness often experience insecurity accessing menstrual products, yet the most vulnerable were people experiencing unsheltered homelessness who are less likely to gain access to these products [<a href="#pone.0303378.ref033" class="ref-tip">33</a>]. Maroko et al. conducted a mixed-methods study also in NYC among people experiencing homelessness, and found that access to clean, private, and available sanitation facilities are critical issues and unmet needs among this population [<a href="#pone.0303378.ref034" class="ref-tip">34</a>]. Sommer et al. qualitative study also among NYC people experiencing homelessness, reported lack of clean and safe spaces to manage menstruation, and inadequate bathing and laundering access [<a href="#pone.0303378.ref035" class="ref-tip">35</a>]. Yet, our study is one of the first to describe MH among PWID.</p> <a id="article1.body1.sec4.p6" name="article1.body1.sec4.p6" class="link-target"></a><p>There are some limitations to this study. Study sampling was nonprobability sampling, given the difficulty of reaching the target population. Therefore, caution must be used when interpreting results or generalizing. We used the same population to validate the scale and to identify correlates, which could incorporate bias. Most of the variables in this scale were based on well-defined concepts. However, some variables had less defined cutoffs points, such as number of baths per week and time spent walking to sanitation facilities. These two variables have not been well explored in past literature, but we argue are important for MH access and for mobile populations who do not have permanent housing and limited access to these services. Permanent housing in this study included all participants who were not classified as individuals experiencing homelessness, but should not be interpreted as someone with stable long-term housing. Rather, we focused on the place or structure where participants reported sleeping, which can provide some access to WASH and protect them from the elements. However, this does not imply participants may have permanent access to that infrastructure. Participants who were classified as living in permanent housing could also be experiencing housing instability in ways not explored in this analysis. The participant dataset included only one trans man, which limited the validation and results of this study to the experiences of cis women who inject drugs. We included two cities that are part of a binational metropolitan area; however, due to the sample size, we were unable to assess if the scale offers similar reliability in both locations. Also, because we used latent variables that included self-reported information, our findings could have been influenced by social desirability or motivation biases [<a href="#pone.0303378.ref022" class="ref-tip">22</a>]. Moreover, this scale aimed to measure one of the five domains of MH and cannot measure MH comprehensively.</p> <a id="article1.body1.sec4.p7" name="article1.body1.sec4.p7" class="link-target"></a><p>Recent studies are developing scales to include measures of the other four components of MH focused on menstrual education, health care access, respectful environment and freedom to participate in all spheres of life during menstruation [<a href="#pone.0303378.ref001" class="ref-tip">1</a>,<a href="#pone.0303378.ref016" class="ref-tip">16</a>]. MH was defined in 2021[<a href="#pone.0303378.ref001" class="ref-tip">1</a>] and the JMP Gender in WASH short list of indicators that will be measured across countries was developed by Hennegen et al in 2023 [<a href="#pone.0303378.ref016" class="ref-tip">16</a>]. Our data used in this MH-WASH scale was collected in 2020 and 2021 while these other scales were developed. Our MH-WASH scale’s strengths are in its brevity, important for studies that do not focus on MH across all five domains, and it is tested in a vulnerable population, PWID who are largely unhoused, a population rarely studied in MH research. Our scale could be tested in other mobile or vulnerable populations, like refugees, internally displaced people, asylum seekers and returnees [<a href="#pone.0303378.ref036" class="ref-tip">36</a>].</p> <a id="article1.body1.sec4.p8" name="article1.body1.sec4.p8" class="link-target"></a><p>MH is an essential part of health for women and people who menstruate. However, we found that access to WASH services needed to secure MH is not universal among PWID living in the Tijuana-San Diego region. In our study, we found that less than 80% of participants had access to >4 showers/baths per week, had available handwashing facilities (with soap and water) and soap for any use, and access to improved, non-shared, and private toilet facilities. We identified gaps in access to WASH services important for achieving MH, which requires us to shift our focus and think about the implications of housing status among PWID. For instance, availability of handwashing facilities with soap and water was identified as an important need among individuals experiencing homelessness, participants who reported sex work, and those living in Tijuana. Additionally, improvements are needed to bring access to bathing and safe, private, and non-shared sanitation facilities for participants experiencing both sheltered and unsheltered homelessness. Availability of improved water sources for handwashing should be increased among participants living in Tijuana and those who reported sex work.</p> <a id="article1.body1.sec4.p9" name="article1.body1.sec4.p9" class="link-target"></a><p>The prevalence of secondary amenorrhea (i.e., absence of menstrual cycles for 12+ months) among women of reproductive age is up to 3% (ranging between 1.0% to 5.0%) in different contexts [<a href="#pone.0303378.ref037" class="ref-tip">37</a>–<a href="#pone.0303378.ref039" class="ref-tip">39</a>], and in our study among PWID, we found 17% of participants reported secondary amenorrhea. Our study supports previous research reporting that substance use is a risk factor for amenorrhea [<a href="#pone.0303378.ref040" class="ref-tip">40</a>,<a href="#pone.0303378.ref041" class="ref-tip">41</a>]. Harlow et al. (2003) estimated injection drug use nearly quadrupled the risk of amenorrhea among 1075 women aged 20–44 years in the US (3%), while among our study participants prevalence of amenorrhea was almost six times that of the general population of women of reproductive age [<a href="#pone.0303378.ref040" class="ref-tip">40</a>]. Further, in Kaiser et al.’s study among women of reproductive age enrolled on substance use disorder treatment, 42% reported secondary amenorrhea, which was more than double that in our study [<a href="#pone.0303378.ref003" class="ref-tip">3</a>]. Menstrual cycles can be affected by body weight changes, chronic illness, eating and exercise habits, stress, and medication use [<a href="#pone.0303378.ref042" class="ref-tip">42</a>,<a href="#pone.0303378.ref043" class="ref-tip">43</a>]. Despite the association between substance use and amenorrhea, it is important to ensure medical care among women, non-binary, and transgender men of reproductive age without menstrual cycles to identify and treat physiological causes such as premature menopause, polycystic ovarian syndrome, or hyperprolactinemia [<a href="#pone.0303378.ref042" class="ref-tip">42</a>]. The ‘health care’ domain of MH defined as the access to “diagnosis, treatment, and care for menstrual cycle-related discomforts and disorders, including access to appropriate health services and resources, pain relief, and strategies for self-care” is highly important among PWID who menstruate and should be explored in future research [<a href="#pone.0303378.ref001" class="ref-tip">1</a>].</p> </div> <div xmlns:plos="http://plos.org" id="section5" class="section toc-section"><a id="sec018" name="sec018" data-toc="sec018" class="link-target" title="Conclusions"></a><h2>Conclusions</h2><a id="article1.body1.sec5.p1" name="article1.body1.sec5.p1" class="link-target"></a><p>We constructed and validated, in a US-Mexico cohort population, a novel and reliable scale to measure the WASH domain of MH that can be used to assess MH among marginalized populations including women who inject drugs and who are experiencing homelessness in English- and Spanish-speaking contexts. According to the validity assessments employed in this analysis, the ‘<em>MH WASH Domain Scale-12’</em> contained two domains: <em>WASH availability</em> and <em>WASH security</em>. The performance of these sub-scales was assessed theoretically and empirically using a suite of available statistical tools. Overall performance was deemed to be adequate, and further research should be conducted to validate and compare this scale and its derived sub-scales among other marginalized populations, such as non-binary and trans men who menstruate who also experience WASH insecurity and other mobile populations in emergency setting or are experiencing housing insecurity. This is a short and easy-to-use scale which may be useful for rapid assessment and for inclusion in longer surveys. Access to a household or a shelter was significantly associated with higher scores on our ‘<em>MH WASH Domain Scale-12’</em> which highlights the importance of housing security to achieve MH.</p> <a id="article1.body1.sec5.p2" name="article1.body1.sec5.p2" class="link-target"></a><p>We identified specific WASH needs by housing status, city of residence, and reported sex work among PWID that require further attention. Moreover, women who inject drugs of reproductive age had high prevalence of amenorrhea, which requires medical care to rule out other diagnoses. Interventions to improve access to MH-WASH services are needed among women who menstruate and who inject drugs, particularly for bathing, available handwashing facilities and soap, and improved, non-shared, and private sanitation facilities.</p> </div> <div xmlns:plos="http://plos.org" id="section6" class="section toc-section"><a id="sec019" name="sec019" data-toc="sec019" class="link-target" title="Supporting information"></a><h2>Supporting information</h2><div class="figshare_widget" doi="10.1371/journal.pone.0303378"></div><div class="supplementary-material"><a name="pone.0303378.s001" id="pone.0303378.s001" class="link-target"></a><h3 class="siTitle title-small"><a href="article/file?type=supplementary&id=10.1371/journal.pone.0303378.s001">S1 Table. </a>Variance and correlation per item by two factors among the ‘<em>Menstrual Health WASH Domain Scale-12’</em> items.</h3><p class="siDoi"><a href="https://doi.org/10.1371/journal.pone.0303378.s001">https://doi.org/10.1371/journal.pone.0303378.s001</a></p><a id="article1.body1.sec6.supplementary-material1.caption1.p1" name="article1.body1.sec6.supplementary-material1.caption1.p1" class="link-target"></a><p class="postSiDOI">(DOCX)</p> </div><div class="supplementary-material"><a name="pone.0303378.s002" id="pone.0303378.s002" class="link-target"></a><h3 class="siTitle title-small"><a href="article/file?type=supplementary&id=10.1371/journal.pone.0303378.s002">S1 File. </a></h3><p class="siDoi"><a href="https://doi.org/10.1371/journal.pone.0303378.s002">https://doi.org/10.1371/journal.pone.0303378.s002</a></p><a id="article1.body1.sec6.supplementary-material2.caption1.p1" name="article1.body1.sec6.supplementary-material2.caption1.p1" class="link-target"></a><p class="postSiDOI">(CSV)</p> </div><div class="supplementary-material"><a name="pone.0303378.s003" id="pone.0303378.s003" class="link-target"></a><h3 class="siTitle title-small"><a href="article/file?type=supplementary&id=10.1371/journal.pone.0303378.s003">S1 Database. </a></h3><p class="siDoi"><a href="https://doi.org/10.1371/journal.pone.0303378.s003">https://doi.org/10.1371/journal.pone.0303378.s003</a></p><a id="article1.body1.sec6.supplementary-material3.caption1.p1" name="article1.body1.sec6.supplementary-material3.caption1.p1" class="link-target"></a><p class="postSiDOI">(CSV)</p> </div></div> <div xmlns:plos="http://plos.org" class="section toc-section"><a id="ack" name="ack" data-toc="ack" title="Acknowledgments" class="link-target"></a><h2>Acknowledgments</h2> <a id="article1.back1.ack1.p1" name="article1.back1.ack1.p1" class="link-target"></a><p>We thank the <em>La Frontera</em> cohort project binational staff and the study participants from Tijuana and San Diego.</p> </div><div xmlns:plos="http://plos.org" class="toc-section"><a id="references" name="references" class="link-target" data-toc="references" title="References"></a><h2>References</h2><ol class="references"><li id="ref1"><span class="order">1. </span><a name="pone.0303378.ref001" id="pone.0303378.ref001" class="link-target"></a>Hennegan J, Winkler IT, Bobel C, Keiser D, Hampton J, Larsson G, et al. Menstrual health: a definition for policy, practice, and research. Sex Reprod Health Matters. 2021;29: 1911618. pmid:33910492 <ul class="reflinks" data-doi="10.1080/26410397.2021.1911618"><li><a href="https://doi.org/10.1080/26410397.2021.1911618" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/33910492" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Menstrual+health%3A+a+definition+for+policy%2C+practice%2C+and+research.+Hennegan+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref2"><span class="order">2. </span><a name="pone.0303378.ref002" id="pone.0303378.ref002" class="link-target"></a>Kamau R, Martin JS, Calderón-Villarreal A, Jacobs C. Inclusivity starts with language. The Lancet. 2022;399: 434–435. pmid:35093223 <ul class="reflinks" data-doi="10.1016/S0140-6736(21)02502-2"><li><a href="https://doi.org/10.1016/S0140-6736(21)02502-2" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/35093223" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Inclusivity+starts+with+language+Kamau+2022" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref3"><span class="order">3. </span><a name="pone.0303378.ref003" id="pone.0303378.ref003" class="link-target"></a>Keiser V, Parlier-Ahmad AB, Kuhlmann AS, Martin CE. Menstrual Hygiene Needs Among Women Undergoing Substance Use Disorder Treatment. Obstet Gynecol. 2020;136: 768–770. pmid:32925624 <ul class="reflinks" data-doi="10.1097/AOG.0000000000004042"><li><a href="https://doi.org/10.1097/AOG.0000000000004042" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32925624" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Menstrual+Hygiene+Needs+Among+Women+Undergoing+Substance+Use+Disorder+Treatment+Keiser+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref4"><span class="order">4. </span><a name="pone.0303378.ref004" id="pone.0303378.ref004" class="link-target"></a>Friedman J, Calderón-Villarreal A, Adame RC, Abramovitz D, Rafful C, Rangel G, et al. An Ethnographic Assessment of COVID-19‒Related Changes to the Risk Environment for People Who Use Drugs in Tijuana, Mexico. Am J Public Health. 2022;112: S199–S205. pmid:35349326 <ul class="reflinks" data-doi="10.2105/AJPH.2022.306796"><li><a href="https://doi.org/10.2105/AJPH.2022.306796" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/35349326" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=An+Ethnographic+Assessment+of+COVID-19%E2%80%92Related+Changes+to+the+Risk+Environment+for+People+Who+Use+Drugs+in+Tijuana%2C+Mexico.+Friedman+2022" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref5"><span class="order">5. </span><a name="pone.0303378.ref005" id="pone.0303378.ref005" class="link-target"></a>Calderón-Villarreal A, Terry B, Friedman J, González-Olachea SA, Chavez A, Díaz López M, et al. Deported, homeless, and into the canal: Environmental structural violence in the binational Tijuana River. Soc Sci Med. 2022;305: 115044. pmid:35633600 <ul class="reflinks" data-doi="10.1016/j.socscimed.2022.115044"><li><a href="https://doi.org/10.1016/j.socscimed.2022.115044" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/35633600" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Deported%2C+homeless%2C+and+into+the+canal%3A+Environmental+structural+violence+in+the+binational+Tijuana+River.+Calder%C3%B3n-Villarreal+2022" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref6"><span class="order">6. </span><a name="pone.0303378.ref006" id="pone.0303378.ref006" class="link-target"></a>Avelar Portillo LJ, Kayser GL, Ko C, Vasquez A, Gonzalez J, Avelar DJ, et al. Water, Sanitation, and Hygiene (WaSH) insecurity in unhoused communities of Los Angeles, California. Int J Equity Health. 2023;22: 108. pmid:37264411 <ul class="reflinks" data-doi="10.1186/s12939-023-01920-8"><li><a href="https://doi.org/10.1186/s12939-023-01920-8" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/37264411" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Water%2C+Sanitation%2C+and+Hygiene+%28WaSH%29+insecurity+in+unhoused+communities+of+Los+Angeles%2C+California.+Avelar+Portillo+2023" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref7"><span class="order">7. </span><a name="pone.0303378.ref007" id="pone.0303378.ref007" class="link-target"></a>Ballard AM, Cooper HLF, Young AM, Caruso BA. ‘You feel how you look’: Exploring the impacts of unmet water, sanitation, and hygiene needs among rural people experiencing homelessness and their intersection with drug use. PLOS Water. 2022;1: e0000019. <ul class="reflinks" data-doi="10.1371/journal.pwat.0000019"><li><a href="https://doi.org/10.1371/journal.pwat.0000019" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=%E2%80%98You+feel+how+you+look%E2%80%99%3A+Exploring+the+impacts+of+unmet+water%2C+sanitation%2C+and+hygiene+needs+among+rural+people+experiencing+homelessness+and+their+intersection+with+drug+use.+Ballard+2022" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref8"><span class="order">8. </span><a name="pone.0303378.ref008" id="pone.0303378.ref008" class="link-target"></a>Kayser GL, Rao N, Jose R, Raj A. Water, sanitation and hygiene: measuring gender equality and empowerment. Bull World Health Organ. 2019;97: 432–440. pmid:31210683 <ul class="reflinks" data-doi="10.2471/BLT.18.223305"><li><a href="https://doi.org/10.2471/BLT.18.223305" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/31210683" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Water%2C+sanitation+and+hygiene%3A+measuring+gender+equality+and+empowerment+Kayser+2019" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref9"><span class="order">9. </span><a name="pone.0303378.ref009" id="pone.0303378.ref009" class="link-target"></a>Phillips-Howard PA, Osire E, Akinyi C, Zulaika G, Otieno FO, Mehta SD. Water, sanitation and hygiene at sex work venues to support menstrual needs. Front Public Health. 2024;12. Available: <a href="https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1305601">https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1305601</a> pmid:38481834 <ul class="reflinks"><li><a href="#" data-author="Phillips-Howard" data-cit="Phillips-HowardPA%2C%20OsireE%2C%20AkinyiC%2C%20ZulaikaG%2C%20OtienoFO%2C%20MehtaSD.%20Water%2C%20sanitation%20and%20hygiene%20at%20sex%20work%20venues%20to%20support%20menstrual%20needs.%20Front%20Public%20Health.%202024%3B12.%20Available%3A%20https%3A%2F%2Fwww.frontiersin.org%2Fjournals%2Fpublic-health%2Farticles%2F10.3389%2Ffpubh.2024.1305601%2038481834" data-title="Water%2C%20sanitation%20and%20hygiene%20at%20sex%20work%20venues%20to%20support%20menstrual%20needs." target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/38481834" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Water%2C+sanitation+and+hygiene+at+sex+work+venues+to+support+menstrual+needs.+Phillips-Howard+2024" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref10"><span class="order">10. </span><a name="pone.0303378.ref010" id="pone.0303378.ref010" class="link-target"></a>Hennegan J, Brooks DJ, Schwab KJ, Melendez-Torres GJ. Measurement in the study of menstrual health and hygiene: A systematic review and audit. PLOS ONE. 2020;15: e0232935. pmid:32497117 <ul class="reflinks" data-doi="10.1371/journal.pone.0232935"><li><a href="https://doi.org/10.1371/journal.pone.0232935" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32497117" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Measurement+in+the+study+of+menstrual+health+and+hygiene%3A+A+systematic+review+and+audit.+Hennegan+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref11"><span class="order">11. </span><a name="pone.0303378.ref011" id="pone.0303378.ref011" class="link-target"></a>Smith AD, Muli A, Schwab KJ, Hennegan J. National Monitoring for Menstrual Health and Hygiene: Is the Type of Menstrual Material Used Indicative of Needs Across 10 Countries? Int J Environ Res Public Health. 2020;17: 2633. pmid:32290529 <ul class="reflinks" data-doi="10.3390/ijerph17082633"><li><a href="https://doi.org/10.3390/ijerph17082633" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32290529" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=National+Monitoring+for+Menstrual+Health+and+Hygiene%3A+Is+the+Type+of+Menstrual+Material+Used+Indicative+of+Needs+Across+10+Countries%3F+Smith+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref12"><span class="order">12. </span><a name="pone.0303378.ref012" id="pone.0303378.ref012" class="link-target"></a>Calderón-Villarreal A. Taxing women’s bodies: the state of menstrual product taxes in the Americas. Lancet Reg Health—Am. 2024;29: 100637. pmid:38077619 <ul class="reflinks" data-doi="10.1016/j.lana.2023.100637"><li><a href="https://doi.org/10.1016/j.lana.2023.100637" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/38077619" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Taxing+women%E2%80%99s+bodies%3A+the+state+of+menstrual+product+taxes+in+the+Americas+Calder%C3%B3n-Villarreal+2024" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref13"><span class="order">13. </span><a name="pone.0303378.ref013" id="pone.0303378.ref013" class="link-target"></a>WHO, UNICEF. Joint Monitoring Program (JMP). 2020 [cited 14 Dec 2020]. Available: <a href="https://washdata.org/">https://washdata.org/</a>. <ul class="reflinks"><li><a href="#" data-author="" data-cit="WHO%2C%20UNICEF.%20Joint%20Monitoring%20Program%20%28JMP%29.%202020%20%5Bcited%2014%20Dec%202020%5D.%20Available%3A%20https%3A%2F%2Fwashdata.org%2F." data-title="Joint%20Monitoring%20Program%20%28JMP%29." target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=Joint+Monitoring+Program+%28JMP%29.++2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref14"><span class="order">14. </span><a name="pone.0303378.ref014" id="pone.0303378.ref014" class="link-target"></a>Hennegan J, Nansubuga A, Smith C, Redshaw M, Akullo A, Schwab KJ. Measuring menstrual hygiene experience: development and validation of the Menstrual Practice Needs Scale (MPNS-36) in Soroti, Uganda. BMJ Open. 2020;10: e034461. pmid:32071187 <ul class="reflinks" data-doi="10.1136/bmjopen-2019-034461"><li><a href="https://doi.org/10.1136/bmjopen-2019-034461" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32071187" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Measuring+menstrual+hygiene+experience%3A+development+and+validation+of+the+Menstrual+Practice+Needs+Scale+%28MPNS-36%29+in+Soroti%2C+Uganda.+Hennegan+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref15"><span class="order">15. </span><a name="pone.0303378.ref015" id="pone.0303378.ref015" class="link-target"></a>Hennegan J, Nansubuga A, Akullo A, Smith C, Schwab KJ. The Menstrual Practices Questionnaire (MPQ): development, elaboration, and implications for future research. Glob Health Action. 2020;13: 1829402. pmid:33052077 <ul class="reflinks" data-doi="10.1080/16549716.2020.1829402"><li><a href="https://doi.org/10.1080/16549716.2020.1829402" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/33052077" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=The+Menstrual+Practices+Questionnaire+%28MPQ%29%3A+development%2C+elaboration%2C+and+implications+for+future+research.+Hennegan+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref16"><span class="order">16. </span><a name="pone.0303378.ref016" id="pone.0303378.ref016" class="link-target"></a>Hennegan J, Caruso BA, Zulaika G, Torondel B, Haver J, Phillips-Howard PA, et al. Indicators for National and Global Monitoring of Girls’ Menstrual Health and Hygiene: Development of a Priority Shortlist. J Adolesc Health. 2023;73: 992–1001. pmid:37737755 <ul class="reflinks" data-doi="10.1016/j.jadohealth.2023.07.017"><li><a href="https://doi.org/10.1016/j.jadohealth.2023.07.017" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/37737755" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Indicators+for+National+and+Global+Monitoring+of+Girls%E2%80%99+Menstrual+Health+and+Hygiene%3A+Development+of+a+Priority+Shortlist.+Hennegan+2023" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref17"><span class="order">17. </span><a name="pone.0303378.ref017" id="pone.0303378.ref017" class="link-target"></a>Strathdee SA, Abramovitz D, Harvey-Vera A, Vera CF, Rangel G, Artamonova I, et al. Prevalence and correlates of SARS-CoV-2 seropositivity among people who inject drugs in the San Diego-Tijuana border region. PLOS ONE. 2021;16: e0260286. pmid:34807963 <ul class="reflinks" data-doi="10.1371/journal.pone.0260286"><li><a href="https://doi.org/10.1371/journal.pone.0260286" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/34807963" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Prevalence+and+correlates+of+SARS-CoV-2+seropositivity+among+people+who+inject+drugs+in+the+San+Diego-Tijuana+border+region.+Strathdee+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref18"><span class="order">18. </span><a name="pone.0303378.ref018" id="pone.0303378.ref018" class="link-target"></a>US Department of Housing and Urban Development. The 2020 Annual Homeless Assessment Report (AHAR) to Congress. 2021. Available: <a href="https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf">https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf</a>. <ul class="find-nolinks"></ul></li><li id="ref19"><span class="order">19. </span><a name="pone.0303378.ref019" id="pone.0303378.ref019" class="link-target"></a>Orange County. HMIS Related HUD Definitions. 2014. Available: <a href="http://www.ochmis.org/documents/file_HMIS_Related_HUD_Definitions.pdf">http://www.ochmis.org/documents/file_HMIS_Related_HUD_Definitions.pdf</a>. <ul class="reflinks"><li><a href="#" data-author="" data-cit="Orange%20County.%20HMIS%20Related%20HUD%20Definitions.%202014.%20Available%3A%20http%3A%2F%2Fwww.ochmis.org%2Fdocuments%2Ffile_HMIS_Related_HUD_Definitions.pdf." data-title="HMIS%20Related%20HUD%20Definitions" target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=HMIS+Related+HUD+Definitions++2014" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref20"><span class="order">20. </span><a name="pone.0303378.ref020" id="pone.0303378.ref020" class="link-target"></a>DeVellis RF. Scale Development: Theory and Applications. Los Angeles; 2016. <ul class="find-nolinks"></ul></li><li id="ref21"><span class="order">21. </span><a name="pone.0303378.ref021" id="pone.0303378.ref021" class="link-target"></a>Boateng GO, Neilands TB, Frongillo EA, Melgar-Quiñonez HR, Young SL. Best Practices for Developing and Validating Scales for Health, Social, and Behavioral Research: A Primer. Front Public Health. 2018;6. Available: <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2018.00149">https://www.frontiersin.org/articles/10.3389/fpubh.2018.00149</a>. pmid:29942800 <ul class="reflinks"><li><a href="#" data-author="Boateng" data-cit="BoatengGO%2C%20NeilandsTB%2C%20FrongilloEA%2C%20Melgar-Qui%C3%B1onezHR%2C%20YoungSL.%20Best%20Practices%20for%20Developing%20and%20Validating%20Scales%20for%20Health%2C%20Social%2C%20and%20Behavioral%20Research%3A%20A%20Primer.%20Front%20Public%20Health.%202018%3B6.%20Available%3A%20https%3A%2F%2Fwww.frontiersin.org%2Farticles%2F10.3389%2Ffpubh.2018.00149.%20doi%3A%2010.3389%2Ffpubh.2018.00149%2029942800" data-title="Best%20Practices%20for%20Developing%20and%20Validating%20Scales%20for%20Health%2C%20Social%2C%20and%20Behavioral%20Research%3A%20A%20Primer." target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/29942800" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Best+Practices+for+Developing+and+Validating+Scales+for+Health%2C+Social%2C+and+Behavioral+Research%3A+A+Primer.+Boateng+2018" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref22"><span class="order">22. </span><a name="pone.0303378.ref022" id="pone.0303378.ref022" class="link-target"></a>Palmer RF, Graham JW, Taylor B, Tatterson J. Construct Validity in Health Behavior Research: Interpreting Latent Variable Models Involving Self-Report and Objective Measures. J Behav Med. 2002;25: 525–550. pmid:12462957 <ul class="reflinks" data-doi="10.1023/a:1020689316518"><li><a href="https://doi.org/10.1023/a:1020689316518" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/12462957" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Construct+Validity+in+Health+Behavior+Research%3A+Interpreting+Latent+Variable+Models+Involving+Self-Report+and+Objective+Measures.+Palmer+2002" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref23"><span class="order">23. </span><a name="pone.0303378.ref023" id="pone.0303378.ref023" class="link-target"></a>Clark LA, Watson D. Constructing validity: Basic issues in objective scale development. Psychol Assess. 1995;7: 309–319. <ul class="reflinks" data-doi="10.1037/1040-3590.7.3.309"><li><a href="https://doi.org/10.1037/1040-3590.7.3.309" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=Constructing+validity%3A+Basic+issues+in+objective+scale+development+Clark+1995" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref24"><span class="order">24. </span><a name="pone.0303378.ref024" id="pone.0303378.ref024" class="link-target"></a>WHO. Monitoring WASH in Health Care Facilities. Final Core Indicators and Questions. 2016. Available: <a href="https://www.who.int/water_sanitation_health/monitoring/coverage/wash-in-hcf-core-questions.pdf">https://www.who.int/water_sanitation_health/monitoring/coverage/wash-in-hcf-core-questions.pdf</a>. <ul class="reflinks"><li><a href="#" data-author="" data-cit="WHO.%20Monitoring%20WASH%20in%20Health%20Care%20Facilities.%20Final%20Core%20Indicators%20and%20Questions.%202016.%20Available%3A%20https%3A%2F%2Fwww.who.int%2Fwater_sanitation_health%2Fmonitoring%2Fcoverage%2Fwash-in-hcf-core-questions.pdf." data-title="Monitoring%20WASH%20in%20Health%20Care%20Facilities.%20Final%20Core%20Indicators%20and%20Questions" target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=Monitoring+WASH+in+Health+Care+Facilities.+Final+Core+Indicators+and+Questions++2016" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref25"><span class="order">25. </span><a name="pone.0303378.ref025" id="pone.0303378.ref025" class="link-target"></a>Akter N, Banu B, Hossain SM, Shakib SH, Awal ASN. Compliance on existing WASH facilities in community clinics of Bangladesh: A comparative study. Heliyon. 2021;7: e07549. pmid:34345735 <ul class="reflinks" data-doi="10.1016/j.heliyon.2021.e07549"><li><a href="https://doi.org/10.1016/j.heliyon.2021.e07549" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/34345735" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Compliance+on+existing+WASH+facilities+in+community+clinics+of+Bangladesh%3A+A+comparative+study.+Akter+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref26"><span class="order">26. </span><a name="pone.0303378.ref026" id="pone.0303378.ref026" class="link-target"></a>Uddin SMN, Walters V, Gaillard JC, Hridi SM, McSherry A. Water, sanitation and hygiene for homeless people. J Water Health. 2016;14: 47–51. pmid:26837829 <ul class="reflinks" data-doi="10.2166/wh.2015.248"><li><a href="https://doi.org/10.2166/wh.2015.248" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/26837829" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Water%2C+sanitation+and+hygiene+for+homeless+people.+Uddin+2016" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref27"><span class="order">27. </span><a name="pone.0303378.ref027" id="pone.0303378.ref027" class="link-target"></a>Ramaiya A, Sood S. What are the psychometric properties of a menstrual hygiene management scale: a community-based cross-sectional study. BMC Public Health. 2020;20: 525. pmid:32306931 <ul class="reflinks" data-doi="10.1186/s12889-020-08627-3"><li><a href="https://doi.org/10.1186/s12889-020-08627-3" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32306931" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=What+are+the+psychometric+properties+of+a+menstrual+hygiene+management+scale%3A+a+community-based+cross-sectional+study.+Ramaiya+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref28"><span class="order">28. </span><a name="pone.0303378.ref028" id="pone.0303378.ref028" class="link-target"></a>Caruso BA, Salinger A, Patrick M, Conrad A, Sinharoy S. A Review of Measures and Indicators for Gender in WASH. 2021. Available: <a href="https://washdata.org/sites/default/files/2021-10/jmp-2021-gender-review-final-report.pdf">https://washdata.org/sites/default/files/2021-10/jmp-2021-gender-review-final-report.pdf</a>. <ul class="reflinks"><li><a href="#" data-author="Caruso" data-cit="CarusoBA%2C%20SalingerA%2C%20PatrickM%2C%20ConradA%2C%20SinharoyS.%20A%20Review%20of%20Measures%20and%20Indicators%20for%20Gender%20in%20WASH.%202021.%20Available%3A%20https%3A%2F%2Fwashdata.org%2Fsites%2Fdefault%2Ffiles%2F2021-10%2Fjmp-2021-gender-review-final-report.pdf." data-title="A%20Review%20of%20Measures%20and%20Indicators%20for%20Gender%20in%20WASH" target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=A+Review+of+Measures+and+Indicators+for+Gender+in+WASH+Caruso+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref29"><span class="order">29. </span><a name="pone.0303378.ref029" id="pone.0303378.ref029" class="link-target"></a>Avelar Portillo LJ, Calderón-Villarreal A, Abramovitz D, Harvey-Vera A, Cassels S, Vera CF, et al. WaSH insecurity and anxiety among people who inject drugs in the Tijuana-San Diego border region. BMC Public Health. 2024;24: 19. pmid:38166866 <ul class="reflinks" data-doi="10.1186/s12889-023-17341-9"><li><a href="https://doi.org/10.1186/s12889-023-17341-9" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/38166866" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=WaSH+insecurity+and+anxiety+among+people+who+inject+drugs+in+the+Tijuana-San+Diego+border+region.+Avelar+Portillo+2024" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref30"><span class="order">30. </span><a name="pone.0303378.ref030" id="pone.0303378.ref030" class="link-target"></a>Caruso BA, Conrad A, Salinger A, Patrick M, Youm A, Sinharoy S. A Conceptual Framework to Inform National and Global Monitoring of Gender Equality in WASH. 2021. Available: <a href="https://washdata.org/sites/default/files/2021-10/jmp-2021-gender-review-conceptual-framework.pdf">https://washdata.org/sites/default/files/2021-10/jmp-2021-gender-review-conceptual-framework.pdf</a>. <ul class="reflinks"><li><a href="#" data-author="Caruso" data-cit="CarusoBA%2C%20ConradA%2C%20SalingerA%2C%20PatrickM%2C%20YoumA%2C%20SinharoyS.%20A%20Conceptual%20Framework%20to%20Inform%20National%20and%20Global%20Monitoring%20of%20Gender%20Equality%20in%20WASH.%202021.%20Available%3A%20https%3A%2F%2Fwashdata.org%2Fsites%2Fdefault%2Ffiles%2F2021-10%2Fjmp-2021-gender-review-conceptual-framework.pdf." data-title="A%20Conceptual%20Framework%20to%20Inform%20National%20and%20Global%20Monitoring%20of%20Gender%20Equality%20in%20WASH" target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=A+Conceptual+Framework+to+Inform+National+and+Global+Monitoring+of+Gender+Equality+in+WASH+Caruso+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref31"><span class="order">31. </span><a name="pone.0303378.ref031" id="pone.0303378.ref031" class="link-target"></a>Carrard N, MacArthur J, Leahy C, Soeters S, Willetts J. The water, sanitation and hygiene gender equality measure (WASH-GEM): Conceptual foundations and domains of change. Womens Stud Int Forum. 2022;91: 102563. <ul class="reflinks" data-doi="10.1016/j.wsif.2022.102563"><li><a href="https://doi.org/10.1016/j.wsif.2022.102563" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=The+water%2C+sanitation+and+hygiene+gender+equality+measure+%28WASH-GEM%29%3A+Conceptual+foundations+and+domains+of+change.+Carrard+2022" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref32"><span class="order">32. </span><a name="pone.0303378.ref032" id="pone.0303378.ref032" class="link-target"></a>Calderón-Villarreal A, Avelar Portillo LJ, Abramovitz D, Goldenberg S, Flanigan S, Quintana PJE, et al. Water, sanitation, and hygiene access among people who inject drugs in Tijuana and San Diego in 2020–2021: a cross-sectional study. Int J Equity Health. 2024;23: 79. pmid:38644494 <ul class="reflinks" data-doi="10.1186/s12939-024-02163-x"><li><a href="https://doi.org/10.1186/s12939-024-02163-x" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/38644494" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Water%2C+sanitation%2C+and+hygiene+access+among+people+who+inject+drugs+in+Tijuana+and+San+Diego+in+2020%E2%80%932021%3A+a+cross-sectional+study.+Calder%C3%B3n-Villarreal+2024" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref33"><span class="order">33. </span><a name="pone.0303378.ref033" id="pone.0303378.ref033" class="link-target"></a>Gruer C, Hopper K, Smith RC, Kelly E, Maroko A, Sommer M. Seeking menstrual products: a qualitative exploration of the unmet menstrual needs of individuals experiencing homelessness in New York City. Reprod Health. 2021;18: 77. pmid:33849575 <ul class="reflinks" data-doi="10.1186/s12978-021-01133-8"><li><a href="https://doi.org/10.1186/s12978-021-01133-8" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/33849575" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Seeking+menstrual+products%3A+a+qualitative+exploration+of+the+unmet+menstrual+needs+of+individuals+experiencing+homelessness+in+New+York+City.+Gruer+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref34"><span class="order">34. </span><a name="pone.0303378.ref034" id="pone.0303378.ref034" class="link-target"></a>Maroko AR, Hopper K, Gruer C, Jaffe M, Zhen E, Sommer M. Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York. PLOS ONE. 2021;16: e0252946. pmid:34161351 <ul class="reflinks" data-doi="10.1371/journal.pone.0252946"><li><a href="https://doi.org/10.1371/journal.pone.0252946" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/34161351" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Public+restrooms%2C+periods%2C+and+people+experiencing+homelessness%3A+An+assessment+of+public+toilets+in+high+needs+areas+of+Manhattan%2C+New+York.+Maroko+2021" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref35"><span class="order">35. </span><a name="pone.0303378.ref035" id="pone.0303378.ref035" class="link-target"></a>Sommer M, Gruer C, Smith RC, Maroko A, Kim Hopper. Menstruation and homelessness: Challenges faced living in shelters and on the street in New York City. Health Place. 2020;66: 102431. pmid:32987242 <ul class="reflinks" data-doi="10.1016/j.healthplace.2020.102431"><li><a href="https://doi.org/10.1016/j.healthplace.2020.102431" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/32987242" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Menstruation+and+homelessness%3A+Challenges+faced+living+in+shelters+and+on+the+street+in+New+York+City.+Sommer+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref36"><span class="order">36. </span><a name="pone.0303378.ref036" id="pone.0303378.ref036" class="link-target"></a>UNHCR. Who we protect. In: UNHCR [Internet]. 2024 [cited 5 Mar 2024]. Available: <a href="https://www.unhcr.org/about-unhcr/who-we-protect">https://www.unhcr.org/about-unhcr/who-we-protect</a>. <ul class="find-nolinks"></ul></li><li id="ref37"><span class="order">37. </span><a name="pone.0303378.ref037" id="pone.0303378.ref037" class="link-target"></a>Schachter M, Shoham Z. Amenorrhea during the reproductive years—is it safe? Fertil Steril. 1994;62: 1–16. pmid:8005272 <ul class="reflinks" data-doi="10.1016/s0015-0282(16)56808-3"><li><a href="https://doi.org/10.1016/s0015-0282(16)56808-3" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/8005272" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Amenorrhea+during+the+reproductive+years%E2%80%94is+it+safe+Schachter+1994" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref38"><span class="order">38. </span><a name="pone.0303378.ref038" id="pone.0303378.ref038" class="link-target"></a>Khan NT, Jameel N. Amenorrhea-An abnormal cessation of normal menstrual cycle. Clin J Obstet Gynecol. 2020;3: 033–036. <ul class="reflinks" data-doi="10.29328/journal.cjog.1001046"><li><a href="https://doi.org/10.29328/journal.cjog.1001046" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=Amenorrhea-An+abnormal+cessation+of+normal+menstrual+cycle.+Khan+2020" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref39"><span class="order">39. </span><a name="pone.0303378.ref039" id="pone.0303378.ref039" class="link-target"></a>Nawaz G, Rogol AD. Amenorrhea. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023. Available: <a href="http://www.ncbi.nlm.nih.gov/books/NBK482168/">http://www.ncbi.nlm.nih.gov/books/NBK482168/</a>. <ul class="find-nolinks"></ul></li><li id="ref40"><span class="order">40. </span><a name="pone.0303378.ref040" id="pone.0303378.ref040" class="link-target"></a>Harlow SD, Cohen M, Ohmit SE, Schuman P, Cu-Uvin S, Lin X, et al. Substance use and psychotherapeutic medications: A likely contributor to menstrual disorders in women who are seropositive for human immunodeficiency virus. Am J Obstet Gynecol. 2003;188: 881–886. pmid:12712080 <ul class="reflinks" data-doi="10.1067/mob.2003.209"><li><a href="https://doi.org/10.1067/mob.2003.209" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/12712080" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Substance+use+and+psychotherapeutic+medications%3A+A+likely+contributor+to+menstrual+disorders+in+women+who+are+seropositive+for+human+immunodeficiency+virus.+Harlow+2003" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref41"><span class="order">41. </span><a name="pone.0303378.ref041" id="pone.0303378.ref041" class="link-target"></a>Mburu G, Ndimbii J, Ayon S, Mlewa O, Mbizvo M, Kihara C, et al. Contraceptive Use Among Women Who Inject Drugs: Motivators, Barriers, and Unmet Needs. Womens Reprod Health. 2018;5: 99–116. <ul class="reflinks" data-doi="10.1080/23293691.2018.1463737"><li><a href="https://doi.org/10.1080/23293691.2018.1463737" data-author="doi-provided" data-cit="doi-provided" data-title="doi-provided" target="_new" title="Go to article"> View Article </a></li><li><a href="http://scholar.google.com/scholar?q=Contraceptive+Use+Among+Women+Who+Inject+Drugs%3A+Motivators%2C+Barriers%2C+and+Unmet+Needs.+Mburu+2018" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref42"><span class="order">42. </span><a name="pone.0303378.ref042" id="pone.0303378.ref042" class="link-target"></a>Klein DA, Paradise SL, Reeder RM. Amenorrhea: A Systematic Approach to Diagnosis and Management. Am Fam Physician. 2019;100: 39–48. pmid:31259490 <ul class="reflinks"><li><a href="#" data-author="Klein" data-cit="KleinDA%2C%20ParadiseSL%2C%20ReederRM.%20Amenorrhea%3A%20A%20Systematic%20Approach%20to%20Diagnosis%20and%20Management.%20Am%20Fam%20Physician.%202019%3B100%3A%2039%E2%80%9348.%2031259490" data-title="Amenorrhea%3A%20A%20Systematic%20Approach%20to%20Diagnosis%20and%20Management." target="_new" title="Go to article in CrossRef"> View Article </a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/31259490" target="_new" title="Go to article in PubMed"> PubMed/NCBI </a></li><li><a href="http://scholar.google.com/scholar?q=Amenorrhea%3A+A+Systematic+Approach+to+Diagnosis+and+Management.+Klein+2019" target="_new" title="Go to article in Google Scholar"> Google Scholar </a></li></ul></li><li id="ref43"><span class="order">43. </span><a name="pone.0303378.ref043" id="pone.0303378.ref043" class="link-target"></a>Suri R, Altshuler L. Menstrual Cycles and Stress. In: Fink G, editor. Encyclopedia of Stress (Second Edition). New York: Academic Press; 2007. pp. 706–711. <a href="https://doi.org/10.1016/B978-012373947-6.00256%E2%80%937">https://doi.org/10.1016/B978-012373947-6.00256–7</a> <ul class="find-nolinks"></ul></li></ol></div> <div class="ref-tooltip"> <div class="ref_tooltip-content"> </div> </div> </div> </div> </div> </section> <aside class="article-aside">  <div class="dload-menu"> <div class="dload-pdf"> <a href="/plosone/article/file?id=10.1371/journal.pone.0303378&type=printable" id="downloadPdf" target="_blank">Download PDF</a> </div> <div data-js-tooltip-hover="trigger" class="dload-hover">  <ul class="dload-xml" data-js-tooltip-hover="target"> <li><a href="/plosone/article/citation?id=10.1371/journal.pone.0303378" id="downloadCitation">Citation</a></li> <li><a href="/plosone/article/file?id=10.1371/journal.pone.0303378&type=manuscript" id="downloadXml">XML</a> </li> </ul> </div> </div> <div class="aside-container"> <div class="print-article" id="printArticle" data-js-tooltip-hover="trigger"> <a href="#" onclick="window.print(); return false;" class="preventDefault" id="printBrowser">Print</a> </div> <div class="share-article" id="shareArticle" data-js-tooltip-hover="trigger"> Share <ul data-js-tooltip-hover="target" class="share-options" id="share-options"> <li><a href="https://www.reddit.com/submit?url=https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378" id="shareReddit" target="_blank" title="Submit to Reddit"><img src="/resource/img/icon.reddit.16.png" width="16" height="16" alt="Reddit">Reddit</a></li> <li><a href="https://www.facebook.com/share.php?u=https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378&t=A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs" id="shareFacebook" target="_blank" title="Share on Facebook"><img src="/resource/img/icon.fb.16.png" width="16" height="16" alt="Facebook">Facebook</a></li> <li><a href="https://www.linkedin.com/shareArticle?url=https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378&title=A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs&summary=Checkout this article I found at PLOS" id="shareLinkedIn" target="_blank" title="Add to LinkedIn"><img src="/resource/img/icon.linkedin.16.png" width="16" height="16" alt="LinkedIn">LinkedIn</a></li> <li><a href="https://www.mendeley.com/import/?url=https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378" id="shareMendeley" target="_blank" title="Add to Mendeley"><img src="/resource/img/icon.mendeley.16.png" width="16" height="16" alt="Mendeley">Mendeley</a></li> <li><a href="https://twitter.com/intent/tweet?url=https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378&text=%23PLOSONE%3A%20A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs" target="_blank" title="share on Twitter" id="twitter-share-link"><img src="/resource/img/icon.twtr.16.png" width="16" height="16" alt="Twitter">Twitter</a></li> <li><a href="mailto:?subject=A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs&body=I%20thought%20you%20would%20find%20this%20article%20interesting.%20From%20PLOS ONE:%20https%3A%2F%2Fdx.plos.org%2F10.1371%2Fjournal.pone.0303378" id="shareEmail" rel="noreferrer" aria-label="Email"><img src="/resource/img/icon.email.16.png" width="16" height="16" alt="Email">Email</a></li> <script src="/resource/js/components/tweet140.js" type="text/javascript"></script> </ul> </div> </div>  <script src="https://crossmark-cdn.crossref.org/widget/v2.0/widget.js"></script> <a aria-label="Check for updates via CrossMark" data-target="crossmark"> <img alt="Check for updates via CrossMark" width="150" src="https://crossmark-cdn.crossref.org/widget/v2.0/logos/CROSSMARK_BW_horizontal.svg"> </a>  <div class="aside-container collections-aside-container"></div> <div class="skyscraper-container"> <div class="title">Advertisement</div>  <div class='advertisement' id='div-gpt-ad-1458247671871-1' style='width:160px; height:600px;'> <script type='text/javascript'> googletag.cmd.push(function() { googletag.display('div-gpt-ad-1458247671871-1'); }); </script> </div> </div> <div class="subject-areas-container"> <h3>Subject Areas <div id="subjInfo">?</div> <div id="subjInfoText"> <p>For more information about PLOS Subject Areas, click <a href="https://github.com/PLOS/plos-thesaurus/blob/master/README.md" target="_blank" title="Link opens in new window">here</a>.</p> <span class="inline-intro">We want your feedback.</span> Do these Subject Areas make sense for this article? Click the target next to the incorrect Subject Area and let us know. Thanks for your help! </div> </h3> <ul id="subjectList"> <li> <a class="taxo-term" title="Search for articles about Sanitation" href="/plosone/search?filterSubjects=Sanitation&filterJournals=PLoSONE&q=">Sanitation</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Sanitation"><p class="taxo-explain">Is the Subject Area <strong>"Sanitation"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Housing" href="/plosone/search?filterSubjects=Housing&filterJournals=PLoSONE&q=">Housing</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Housing"><p class="taxo-explain">Is the Subject Area <strong>"Housing"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Sex work" href="/plosone/search?filterSubjects=Sex+work&filterJournals=PLoSONE&q=">Sex work</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Sex work"><p class="taxo-explain">Is the Subject Area <strong>"Sex work"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Soaps" href="/plosone/search?filterSubjects=Soaps&filterJournals=PLoSONE&q=">Soaps</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Soaps"><p class="taxo-explain">Is the Subject Area <strong>"Soaps"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Urban areas" href="/plosone/search?filterSubjects=Urban+areas&filterJournals=PLoSONE&q=">Urban areas</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Urban areas"><p class="taxo-explain">Is the Subject Area <strong>"Urban areas"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Hygiene" href="/plosone/search?filterSubjects=Hygiene&filterJournals=PLoSONE&q=">Hygiene</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Hygiene"><p class="taxo-explain">Is the Subject Area <strong>"Hygiene"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Measurement" href="/plosone/search?filterSubjects=Measurement&filterJournals=PLoSONE&q=">Measurement</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Measurement"><p class="taxo-explain">Is the Subject Area <strong>"Measurement"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> <li> <a class="taxo-term" title="Search for articles about Schools" href="/plosone/search?filterSubjects=Schools&filterJournals=PLoSONE&q=">Schools</a> <span class="taxo-flag"> </span> <div class="taxo-tooltip" data-categoryname="Schools"><p class="taxo-explain">Is the Subject Area <strong>"Schools"</strong> applicable to this article? <button id="noFlag" data-action="remove">Yes</button> <button id="flagIt" value="flagno" data-action="add">No</button></p> <p class="taxo-confirm">Thanks for your feedback.</p> </div> </li> </ul> </div> <div id="subjectErrors"></div> </aside> </div> </main> <footer id="pageftr"> <div class="row"> <div class="block x-small"> <ul class="nav nav-secondary"> <li class="ftr-header"><a href="https://plos.org/our-journals/">Publications</a></li> <li><a href="/plosbiology/" id="ftr-bio">PLOS Biology</a></li> <li><a href="/climate/" id="ftr-climate">PLOS Climate</a></li> <li><a href="/complexsystems/" id="ftr-complex-systems">PLOS Complex Systems</a></li> <li><a href="/ploscompbiol/" id="ftr-compbio">PLOS Computational Biology</a></li> <li><a href="/digitalhealth/" id="ftr-digitalhealth">PLOS Digital Health</a></li> <li><a href="/plosgenetics/" id="ftr-gen">PLOS Genetics</a></li> <li><a href="/globalpublichealth/" id="ftr-globalpublichealth">PLOS Global Public Health</a></li> </ul> </div> <div class="block x-small"> <ul class="nav nav-secondary"> <li class="ftr-header"> </li> <li><a href="/plosmedicine/" id="ftr-med">PLOS Medicine</a></li> <li><a href="/mentalhealth/" id="ftr-mental-health">PLOS Mental Health</a></li> <li><a href="/plosntds/" id="ftr-ntds">PLOS Neglected Tropical Diseases</a></li> <li><a href="/plosone/" id="ftr-one">PLOS One</a></li> <li><a href="/plospathogens/" id="ftr-path">PLOS Pathogens</a></li> <li><a href="/sustainabilitytransformation/" id="ftr-sustainabilitytransformation">PLOS Sustainability and Transformation</a></li> <li><a href="/water/" id="ftr-water">PLOS Water</a></li> </ul> </div> <div class="block xx-small"> <ul class="nav nav-tertiary"> <li> <a href="https://plos.org" id="ftr-home">Home</a> </li> <li> <a href="https://blogs.plos.org" id="ftr-blog">Blogs</a> </li> <li> <a href="https://collections.plos.org/" id="ftr-collections">Collections</a> </li> <li> <a href="mailto:webmaster@plos.org" id="ftr-feedback">Give feedback</a> </li> <li> <a href="/plosone/lockss-manifest" id="ftr-lockss">LOCKSS</a> </li> </ul> </div> <div class="block xx-small"> <ul class="nav nav-primary"> <li><a href="https://plos.org/privacy-policy" id="ftr-privacy">Privacy Policy</a></li> <li><a href="https://plos.org/terms-of-use" id="ftr-terms">Terms of Use</a></li> <li><a href="https://plos.org/advertise/" id="ftr-advertise">Advertise</a></li> <li><a href="https://plos.org/media-inquiries" id="ftr-media">Media Inquiries</a></li> <li><a href="https://plos.org/contact" id="ftr-contact">Contact</a></li> </ul> </div> </div> <div class="row"> <p> <img src="/resource/img/logo-plos-footer.png" alt="PLOS" class="logo-footer"/> <span class="footer-non-profit-statement">PLOS is a nonprofit 501(c)(3) corporation, #C2354500, based in California, US</span> </p> <div class="block"> </div> </div> <script src="/resource/js/global.js" type="text/javascript"></script> </footer> <script type="text/javascript"> var ArticleData = { doi: '10.1371/journal.pone.0303378', title: '<article-title xmlns:mml=\"http://www.w3.org/1998/Math/MathML\" xmlns:xlink=\"http://www.w3.org/1999/xlink\">A brief instrument measuring the water, sanitation and hygiene domain of menstrual health among women who inject drugs<\/article-title>', date: 'May 10, 2024' }; </script> <script src="/resource/js/components/show_onscroll.js" type="text/javascript"></script> <script src="/resource/js/components/pagination.js" type="text/javascript"></script> <script src="/resource/js/vendor/spin.js" type="text/javascript"></script> <script src="/resource/js/pages/article.js" type="text/javascript"></script> <script src="/resource/js/pages/article_references.js" type="text/javascript"></script> <script src="/resource/js/pages/article_sidebar.js" type="text/javascript"></script> <script src="/resource/js/vendor/foundation/foundation.dropdown.js" type="text/javascript"></script> <script src="/resource/js/components/table_open.js" type="text/javascript"></script> <script src="/resource/js/components/figshare.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery.panzoom.min.js" type="text/javascript"></script> <script src="/resource/js/vendor/jquery.mousewheel.js" type="text/javascript"></script> <script src="/resource/js/components/lightbox.js" type="text/javascript"></script> <script src="/resource/js/pages/article_body.js" type="text/javascript"></script>    <script type="text/x-mathjax-config"> MathJax.Hub.Config({ "HTML-CSS": { scale: 100, availableFonts: ["STIX","TeX"], preferredFont: "STIX", webFont: "STIX-Web", linebreaks: { automatic: false } }, jax: ["input/MathML", "output/HTML-CSS"] }); </script> <script type="text/javascript" src="https://cdnjs.cloudflare.com/ajax/libs/mathjax/2.7.1/MathJax.js?config=MML_HTMLorMML"></script> <div class="reveal-modal-bg"></div> </body> </html>