Access to sanitary products Aberdeen pilot: evaluation report

5. Discussion and conclusions

5.1 Summary of findings

Campaigns and news reporting have suggested that those on a low income may struggle to afford sanitary products as well as other essentials, and that this may have an impact on health and school attendance. However, there is limited evidence on the extent and impact of lack of access to sanitary products in the UK and Scotland. The pilot in Aberdeen was set up to both gain insight into the issue of lack of access to sanitary products and to explore options for providing access to free sanitary products for two groups: people from low income households and for students at school, college and university. The evaluation of the pilot set out five main areas to explore for each group:

• better understanding the context and experience of lack of access to products
• testing approaches to providing access to products
• providing some indicative information on the products required
• assessing the impact of the pilot on participants, and
• assessing the wider impact of the provision on the organisations involved.

The next sections consider what the evaluation findings can tell us on each topic.

What circumstances are people in that mean they cannot access products?

Low income households

Accessing sanitary products had presented difficulties in the past for two thirds of participants signing up with community partners. In general these organisations work with vulnerable populations – those affected by substance misuse, domestic violence, homelessness or food insecurity – or communities with high levels of deprivation, and targeted their pilot provision specifically at low income households. We would therefore expect a high proportion of those accessing the pilot to have experienced difficulties.

The majority of participants signing up through community partners were not in employment and many were reliant on benefits. A high proportion were lone parents. Asked about why they were facing financial difficulties, many respondents highlighted living on a low income – most often due to living on benefits, but also because of problems or delays with benefits, disability or illness, paying off debts and coping as a lone parent.

These findings highlight similar issues to those raised in research with individuals who are struggling to afford other essentials such as food. Available statistics suggest that use of food banks has been rising steeply over the last three years. ^[13] The developing evidence base on food insecurity shows that benefit delays (including sanctions) or changes and low income are the primary drivers of food bank use, as well as low wages, insecure work, and high living costs for those in work. ^[14] Research has also suggested that lone parents, large family households and households where someone is disabled or has a health condition are more likely to be food insecure. ^[15] It is likely that many of the same issues are driving difficulties accessing sanitary products.

The main reasons given for difficulty accessing products by the majority of participants related to living on a low income – not having enough money to buy sanitary products, prioritising between sanitary products and other essentials such as food and energy, and having to buy products for several household members. However, other circumstances relating to menstruation or barriers to access such as embarrassment were highlighted, such as heavy or irregular periods, post-partum bleeding, incontinence, embarrassment buying products, lack of access to products locally, and abusive or controlling relationships.

The pilot findings do not indicate how widespread lack of access to sanitary products is in the general population. The findings from community partners do, however, highlight that this is an issue faced by some of those living on low incomes – likely those who are living in severe poverty or are in income crisis and struggling to afford other essentials for themselves and their family.

Educational settings

Turning to the educational settings, as would be expected a smaller proportion of students had experienced difficulties accessing products compared to community participants; around a third of participants at college or university, and a fifth of participants in the schools. We would expect those signing up to the pilot to be more likely to have experienced difficulties than the general population. By comparison, the Young Scot survey found that around a quarter of student respondents had struggled to access products, while the Plan International survey found that 10% of young people surveyed had been unable to afford products. Students mentioned similar reasons for lack of access – being able to afford products on a low income. Not having a product with you when you need one in school or away from the home was also mentioned.

Considered alongside recent survey results, these findings suggest that being able to afford products is an issue for a minority of young people in low income households or students living on low incomes. They also point to a wider issue of access to products when students are 'caught short' in school, college or university settings. This underlines that there are different levels of need and different issues to consider for those on low incomes compared to educational settings.

How do people cope without the products they need and what are the impacts of lack of access to products?

Participants who had experienced not being able to access products in the past generally managed by asking friends or family for products or money to buy products, or using an alternative such as toilet paper – this was comparable across community partners and students. Similarly, the Young Scot survey found that the most common way respondents who had not been able to access products coped was asking someone else for a tampon/towel or using an alternative e.g. toilet paper. The Plan International survey also reported that some young people had, had to ask to 'borrow sanitary wear from a friend', 'improvise sanitary wear' or 'change to a less suitable sanitary product' due to 'affordability issues'.

The most commonly mentioned impact of lack of access to products highlighted was experiencing anxiety or embarrassment about not being able to buy products/ having to use toilet roll, or feeling dirty or degraded about having to use alternatives. Buying cheaper own brand products was also mentioned. A minority of participants mentioned not being able to leave home because they did not have the products they needed, or being forced to steal products. Changing products less often than preferred was also raised – changing tampons less often than recommended has been identified as a risk for Toxic Shock Syndrome

The pilot findings therefore suggest that, for some of those that do not have access to the products they need, this appears to have an impact on their wellbeing and, for a minority, their ability to continue with everyday activities during their period.

What have we learned about different approaches to providing dignified access to free sanitary products?

Low income households

Many of the third sector organisations, who worked with vulnerable women, had already identified lack of access to sanitary products as an issue and were providing products. Their provision was, however, often ad hoc and dependent on donations or finding funding to purchase products.

For low income households, the pilot tested one main model of provision – accessing products via a third sector organisation or community hub in the local area, with distribution coordinated by a local distribution hub ( CFINE). The pilot also explored offering the option of receiving cash or a pre-paid card to allow participants to buy their own products. Variation was also introduced in the way partners provided access to products locally. This does mean there are limitations to what can be concluded regarding different approaches to provision. The evaluation elicited additional feedback on a wider range of options during the end-point survey and interviews to add to our understanding.

As cash and the pre-paid card were offered inconsistently across the partner organisations, it is not possible to draw any firm conclusions from this provision. The limited data collected – on uptake of the card via CFINE and survey responses on interest in the card – does suggest that the pre-paid card option was of interest to some participants. The convenience of using the card to purchase products at the same time as other shopping, being able to choose your own products, and greater dignity were benefits noted.

Providing cash to participants presented ethical concerns for many partner organisations. The pre-paid card presented fewer barriers for partner organisations, although similar concerns were raised by both partner staff and participants around whether the card would be used to buy products. It should be noted that this was not always framed as 'abuse' as such; instead that other essentials ( e.g. for children) may well still be prioritised above sanitary products if there was a choice in how additional funds were spent. There was also a feeling among some staff that these options added an extra layer of unnecessary complexity – if people need products, just give them products. A different type of card system, that is able to limit what can be purchased, may meet with greater approval.

While it is not possible to single out one model of providing access to products as optimal, two important considerations were identified:

• Dignity and respecting participants' privacy – making sure provision is discreet; not being identified as 'in need'; preferably not having to ask someone to access products
• Ease of access – not having to go out of your way to access provision; somewhere that is local, familiar, that you are going to anyway

Having to 'sign up' and ask for products was considered a key barrier in the pilot.

Educational settings

For educational institutions, schools had previously had a stock of sanitary products available for pupils in emergencies; however, monthly provision for all students who wanted it was a new initiative for the schools, college and university. Again, for students the pilot tested one main model of provision – accessing products via designated staff. The pre-paid card was also offered in the college and university, again accessed via designated staff. One school also trialled providing products in the school toilets.

Embarrassment was highlighted as a particular issue for younger people, and having to speak to someone in order to access products was considered to be a key barrier for students and pupils. Limits on the times products could be accessed was another issue raised. While making products freely available in toilets is one way to remove these barriers, there were challenges with this in a school setting due to misuse.

What challenges have arisen?

Many community and education partners were surprised that demand for provision had not been higher – similar issues emerged in both settings. Staff identified raising awareness of the pilot and getting people to take part as a challenge. While staff were clearly supportive of the initiative, prioritising the pilot within busy workloads was difficult for many. Some in community partners reflected that there was probably more they could have done to reach and engage potential participants, but that they just did not have the capacity. In some situations, during community partners' work, raising the topic of sanitary products was not considered appropriate or there were other issues that were considered priorities.

Without baseline data on the extent of lack of access to products and which groups are affected, it is not possible to fully understand whether the pilot was reaching those in need. The sign up process required for data collection seems likely to have limited demand. Other feedback from partners and from survey responses on why some people may not have accessed provision suggest a group who do not require products or did not consider themselves as in need – either because they do not currently menstruate or felt able to afford products.

The majority of participants only used the pilot provision once. Some of these participants may not have reached the point where they needed more products; however, this still leaves a sizeable proportion that did not take up the offer of regular provision. Suggested explanations for this include ease of access ( e.g. whether participants regularly visited the place they accessed products – many people, for example, will not access food banks regularly) and, again, the barrier of having to speak to someone to access products. We are not able to say, however, whether or not these participants had an on-going need for free sanitary products.

Data collection was the most resource-intensive aspect of the pilot. Otherwise, partners were generally very positive about providing sanitary products and did not identify any major practical issues. Many saw providing sanitary products as fitting in to the work they already did and did not feel the provision itself was much of a burden time-wise. Some school staff reported difficulties fitting provision into their workloads, while others felt it complemented health and wellbeing teaching. Most community partners already worked with CFINE as part of the FareShare network, and the distribution of sanitary products fitted into existing processes. A few community partners did reflect that, if uptake had been a lot higher, capacity and storage could have become difficult.

In many community organisations, the pilot activity had been driven by one individual on top of an already busy role. In some community partners, volunteers also played an important role in running the pilot. This highlights the need to consider sustainability in delivery via the third sector and community projects. On the other hand, it should be noted that the demands on organisations would be substantially lower without the data collection requirements and if delivery methods that do not require signing up were adopted ( e.g. making products freely available in toilets or other locations, which some community partners had started doing).

Indicative information on the products required in different settings and costs

More community participants received towels than tampons. The balance of towels to tampons was highest for school pupils and lowest for students. On average partners provided their participants with two packs of products and most participants reported receiving enough products. Being able to provide two or more packs appeared to be important in allowing enough variety in types of product and absorbencies. Flexibility is needed in order to provide enough products for those who have a higher requirement or prefer a wider variety of products.

The majority of participants surveyed said they received a reasonable choice of products. Having a choice of type, absorbency and other practical aspects were highlighted as the most important elements of choice. Generally, a specific brand was not viewed as important and many participants said they were happy to use unbranded products. However, there were a small number of negative comments on supermarket own brand products, while branded products were sometimes discussed as 'better' or 'good quality'. This suggests that offering a range of products that includes brand names may implicitly communicate that recipients are valued.

Considering the overall costs of the pilot provision, products costs made up a fairly small proportion of the total funding. As the data collection element of the pilot was particularly resource intensive it is more relevant to consider the on-going funding provided to CFINE for provision after the pilot: product costs make up a sixth of this funding, with administration the largest cost. The cost of products purchased worked out at an average of 4-6p/unit for supermarket own products and 11-12p/unit for branded products. Using these ranges, the average annual cost per person for products, based on 300 products per year, would be around £15 for supermarket own brand products and £35 for branded products (a higher requirement of around 30 products per cycle would be around £20 to £45).

What impact did providing access to free sanitary products have?

Around two thirds of community participants surveyed thought taking part in the pilot had, had an impact on them. Having more money available to spend on other essential items and feeling less worried about having their period were the most common impacts reported. Similarly, slightly under two thirds of college and university students thought the pilot had an impact on them. The most common impact selected by school, college and university students was being less worried about having their period. Being more able to continue attending school, college or university during their period was selected by a small number of students.

These findings, considered alongside the impact participants reported lack of access to sanitary products had on them, suggest that providing access to free sanitary products for low income households could free up small amounts of money in household budgets for other essentials. It may also have a small impact on wellbeing by reducing anxiety about managing menstruation and allowing those in need to change products more often. Provision could have a larger impact on a minority whose lack of access to products presented a barrier to continuing with day to day activities during their period. For students, the findings suggest that providing products may reduce anxiety about menstruation and, for a minority, may enable their attendance during menstruation. However, only a small sample of participants provided feedback on the impact the pilot had on them so it is not possible to say whether these findings hold across all participants or across the general population.

A broader outcome mentioned by some partners and participants was opening up discussions on the topic of sanitary products and related topics, and feeling more comfortable talking about products and periods. For some schools it highlighted a need for more discussion of this issue and more education around menstruation. Building or strengthening relationships with clients was an additional benefit of taking part in the pilot provision for some partners. The pilot was also seen by some as providing an opportunity for strengthening networks with organisations with similar interests.

Providing products in the future

Participants had diverse views about the best way to provide products in the future. Some differences also emerged in the different settings. Overall, the key considerations identified across the different data sources and different contexts were around ease of access or convenience, provision that is discreet and does not identify recipients as needing help, and preventing misuse or abuse of any provision.

Receiving a card to use in shops was generally seen as a good option across all groups, as it would be convenient and allow choice. A card was least popular among school pupils – perhaps because they do not usually go to the shops to buy their own products. Limiting what a card could be spent on and ensuring the card could be used in a wide enough range of shops were raised as issues to consider by both community participants and partners. Ordering online for delivery by post was also a popular option for most groups because it would be easy and private. Although it would not be accessible for those who did not have easy access the internet.

Community respondents suggested picking up products up from a range of locations in the local area: pharmacies, doctor's surgeries or health clinics, or local buildings such as community centres. These were generally considered to places that were easily accessible to many people.

Having free products available in toilets was a popular option for school, college and university students, but one of the least popular options for community respondents. This may be because it was seen as a good option if you are 'caught short'. The least popular option for school, college and university students was to get free products from a member of school, college or university staff – comments underlined a strong preference for not having to ask someone to access products .

5.2 Key learning points and further research

Provision for low income households

• The evaluation findings develop the evidence base by confirming that access to sanitary products is an issue faced by some of those living on low incomes. They also add to our understanding of the drivers and impacts of this issue. They do not allow us to assess how widespread lack of access to sanitary products is in the general population.
• In addition to living on a low income some other contexts where access to sanitary products can be difficult were raised – e.g. menstrual bleeding issues, post-partum, abusive or controlling relationships. The pilot was not able to develop our understanding of managing menstruation and accessing sufficient products in these circumstances. Further research to explore these specific situations would be helpful, including for example with health visitors, and those who work with women experiencing domestic abuse.
• The majority of participants were already engaging with the organisations involved with the pilot. This underlines that there are likely to have been individuals who are not engaged with services or community projects that the pilot did not reach. Further consideration is needed on how best to reach those who may be in need, but are not engaged with third sector organisations or community projects.
• Partner staff identified raising awareness of the pilot and getting people to take part as a challenge, while a sizeable proportion of participants did not take up the offer of regular provision. The processes imposed by requiring participants to sign up and therefore approach a member of staff or volunteer to access products was identified as a barrier. The way that participants accessed provision was shaped by the need for the pilot to gather data; different approaches could be taken in future provision.
• The reliance of pilot activity, in part, on good will and volunteer time raises the issue of sustainability of delivery via third sector organisations and community projects. Replicability of the pilot activity in areas that do not have an active third sector network or where there is limited access ( e.g. rural areas) is also a consideration.
• The key considerations for provision identified across the different data sources were around ease of access or convenience, provision that is discreet and does not identify recipients as needing help, and preventing misuse or abuse of any provision. Receiving a card and ordering online were popular options – seen as providing choice and being discreet. Although concerns were raised around whether a pre-paid card would be used to buy products, and lack of internet access was highlighted as a potential barrier. Picking up products up from a range of convenient and accessible locations such as pharmacies, doctor's surgeries or health clinics, or community centres was suggested by partners and participants.
• Further exploration of methods for accessing products that do not require talking to someone and other settings such as, for example, community pharmacies would help develop understanding of what a sustainable delivery system that would deliver for all those who need it would look like.

Provision in educational institutions

• The findings also suggest that access to sanitary products is an issue for some in educational settings. Although, as would be expected, a lower proportion of students reported difficulties than community participants. Students raised similar issues related to their or their family's ability to afford products; however, not having a product when you needed one in school or away from the home was also a consideration.
• A small number of students reported that lack of access to products had an impact on their attendance at school, college or university during menstruation. The evaluation is not, however, able to draw any conclusions about the extent to which school pupils and students may be missing education because of challenges associated with managing their periods related to constrained access to sanitary products.
• Embarrassment about periods generally and having to ask a staff member for products were considered to be particular issues in education settings, especially for younger pupils. Schools were reluctant to trial making products available in school toilets because of concerns about misuse and, where this was tested, problems were encountered.
• School staff noted a need for education around menstruation and sanitary products to reduce stigma and normalise discussion of menstruation.
• As for low income households, provision that is easy to access and discreet was highlighted as important. The least popular option for school, college and university students was to get free products from a member staff – underlining the preference for not having to ask someone to access products. As for community participants, receiving a card and ordering online were popular options.
• What students considered convenient was slightly different. Unlike for community participants, having free products available in toilets was a popular option for school, college and university respondents. Reasons included that it was seen as a good option if you are 'caught short'. This highlights that making products freely available in school, college and university toilets requires further exploration, particularly in schools, to understand how the problems identified can be overcome.