1. Introduction

Menstrual poverty, characterized by inadequate access to menstrual hygiene products, education, and facilities, is a pressing issue that significantly impacts the health, education, and social equality of millions of women and girls, particularly in rural China [1]. The problem is exacerbated by financial constraints, stigma, and poor infrastructures, leading to the use of unsanitary alternatives and increasing the risk of infection and reproductive health issues. [2]

In remote rural regions of China, the "White Shell Project" survey revealed that 5% of girls lack access to sanitary products during menstruation, and 13% feel too embarrassed to request funds for pads from their parents [3]. This lack of access not only poses a public health risk but also hinders educational attainment and social participation, with studies indicating associations between menstrual poverty and school absenteeism or dropout rates [1].

Addressing menstrual poverty is crucial for advancing gender equality and social justice, as it is intertwined with the United Nations Sustainable Development Goals (SDGs) [1]. It requires a multifaceted approach, including policy interventions such as tax exemptions on menstrual products, public health initiatives to improve access to hygiene facilities, and educational reforms to increase awareness and break cultural taboos surrounding menstruation. The significance of investigating and addressing menstrual poverty in rural China cannot be overstated. Effective measures to combat this issue are vital for enhancing women's well-being, fostering economic development, and achieving social justice.

Therefore, this paper aims to identify the most effective policy and community-based interventions to alleviate period poverty, considering the social disparities among low-income women and girls in rural China. This investigation will consider economic, societal, and educational factors to develop a well-rounded approach to the problem. By doing so, the research seeks to contribute to the enhancement of women's well-being, the fostering of economic development, and the achievement of social justice in rural China.

China has its particularity when facing the problem of menstrual poverty. The Chinese government has adjusted the tax rate applied to sanitary products, but the tax rate is still at a high level, in contrast to the tax exemption policy for contraceptive drugs and appliances. In China, the value-added tax (VAT) rate on menstrual products is 13 percent, which is the same rate as cigarettes [4]. This tax rate has been criticized by the public because it puts an additional financial burden on women's physiological necessities. Eliminating menstrual poverty therefore requires structural initiatives, including aspects of sex education, gender equality, and distributive justice.

Existing research reveals the challenges that menstrual poverty poses to low-income women and girls' access to sanitation, health care, and education on a global scale, and explores how this issue plays out in urban settings. However, the existing literature also reveals some problems that need to be further studied. These include insufficient attention to the unique challenges of rural areas and insufficient comprehensive analysis of the interlocking effects of economic, social, and educational factors. In addition, existing research has not yet explored the effectiveness of implementing policies and community interventions to reduce menstrual poverty in rural China. Therefore, issues that remain to be researched include a deeper understanding of the challenges of menstrual poverty for marginalized communities, and a combination of knowledge and methods from different fields of public health, economics, sociology, education, and gender studies. Existing research is also more focused on the short-term effects of interventions, and hasn’t adequately explored the role of, for example, gender inequality and power structures in menstrual poverty and how to change these structures, to monitor a more lasting impact.

2. Policy Intervention

2.1. Tax Reductions

The impact of tax relief policies on the price of menstrual products is mainly reflected in reducing product costs and improving affordability. For example, China lowered the VAT rate applicable to sanitary products from 17% to 16% on May 1, 2018, followed by a further reduction to 13% on April 1, 2019 [5]. This reduction in tax rates directly reduces the cost of menstrual products, giving manufacturers the ability to increase profits without increasing retail prices or pass on the benefits of tax relief to consumers in the form of reduced prices, thereby reducing product prices and improving access to these essential hygiene products for low-income women.

When considering policy recommendations, there were proposals to reduce VAT on feminine hygiene products, set up special financial funds to provide free menstrual hygiene products for certain groups of women, and include feminine hygiene products in medical insurance. However, the Ministry of Finance pointed out in its reply that the value-added tax rate applied to sanitary products has been lowered, and reducing the tax rate on sanitary products alone may cause policy comparison among taxpayers in other household goods industries. At the same time, the Ministry of Finance said that it will seriously consider the establishment of special financial funds and strengthen health knowledge publicity and education proposals, and these proposals will be forwarded to relevant departments for reference [6]. Regarding the proposal to include feminine hygiene products in health insurance, the Ministry of Finance considers that it is not in line with the payment of the basic health insurance Fund, because the cost of purchasing sanitary napkins is not a medical expense.

However, the significance of having a period itself exaggerates the gap between biological males and biological females. Other sanitary materials aren’t mandatory. But a woman from 14 to 54 has at least 40 years of menstruating, not considering the ones who started menstruation earlier or ended longer. Even though it's not a medical treatment, it is considered one of the necessities, which definitely should have a tax as low as agricultural products (necessary for living).

Drawing inspiration from the tax policies applied to condoms, which are exempt from value-added tax in China, we can observe a clear public health rationale. Condoms, recognized as medical devices, are tax-exempt under the Provisional Regulations of the People's Republic of China on Value-added Tax. This policy is rooted in the understanding that condoms are essential for the prevention of sexually transmitted infections and for family planning. The exemption serves to lower the cost of production and distribution, enhancing the availability and affordability of condoms, and promoting their use for the protection of individual and public health [3].

2.2. Tax Redemption Proposal

In light of the tax exemption for condoms, it is recommended that similar measures be considered for menstrual products. The absence of import tax on these items would align to make them more accessible and affordable. This approach would support the broader public health objectives and contribute to gender equality by addressing menstrual poverty.

2.3. Public Health Policy

China has established public services that offer free contraceptives, including condoms, as part of a commitment to reproductive health. The initiative, integrated into the national basic public health service project since 2017, aims to provide safe and effective contraceptive options, thereby reducing unintended pregnancies and the spread of sexually transmitted diseases.

It is easily accessible both online and offline for condoms in China. In Guangdong Province, an online platform facilitates the distribution of free contraceptives, accessible via the WeChat public account "Guangdong Free Contraceptives," where residents can order contraceptives online with a minimal delivery fee [7]. Beijing also offers similar services, with the option to order free contraceptives through public WeChat accounts or online platforms, and through self-service machines that dispense condoms using a second-generation ID card [8].

The government is encouraged to extend the free distribution model to menstrual products, providing basic quality pads or tampons at no cost to the public. This initiative would alleviate menstrual poverty and ensure that individuals have access to essential hygiene products, supporting overall public health and gender equity.

3. Menstrual Health Infrastructure

Proper disposal mechanisms and accessible sanitary products are essential components of menstrual health infrastructure, crucial for maintaining hygiene, preventing infections, and reducing environmental pollution. Improper disposal mechanisms for menstrual hygiene products can lead to a variety of negative consequences. Public health can be compromised as menstrual blood, containing bacteria and other harmful substances, poses health risks if not properly managed [1]. Environmentally, the improper disposal of non-biodegradable menstrual products contributes to pollution, with plastics persisting in landfills and water bodies for extended periods, disrupting ecosystems and contaminating natural resources [9]. The presence of chemicals in menstrual products, such as dioxins and fragrances, can leach into the environment, potentially harming aquatic life and increasing pollution levels [4]. Furthermore, inadequate disposal options can lead to embarrassment and perpetuate stigma for individuals, as the lack of discreet disposal methods may cause discomfort and reluctance to seek necessary menstrual hygiene products [2].

To address these issues, the implementation of designated sanitary disposal bins, combined with educational initiatives, and incentivization measures, aims to contribute to effective waste management. The installation of secure sanitary disposal bins in public restrooms, schools, workplaces, and community centers is essential, with regular servicing to ensure hygiene. Educational campaigns will be launched to raise awareness about proper disposal practices and their environmental impacts. The exploration of reward systems for using sanitary bins and the establishment of penalties for non-compliance will encourage responsible disposal practices.

In addition, integrating sanitary products in vending machines addresses accessibility by strategically placing vending machines in key locations for easy access. Some other requirements are subsidizing menstrual products to make them affordable or free for users; offering a range of menstrual products to cater to diverse needs; providing educational information at the point of dispensing; and implementing a robust maintenance schedule to ensure functionality and cleanliness.

A concise and professional implementation plan for integrating sanitary product vending machines to enhance menstrual health infrastructure also highlights strategic locations with high foot traffic and unmet demand, focusing on educational institutions, transit hubs, and community centers for optimal accessibility. A cost-benefit and social impact analysis should be conducted beforehand, including market research and potential health and economic benefits. Regulatory Compliances should adhere to local zoning, health codes, and vending machine regulations, securing necessary permits and licenses. The product selection process should be careful, offering a diverse range of sanitary products, including eco-friendly options.

The budget and secure funding could go through government grants, corporate sponsorships, and potential product surcharges to cover operational costs. Or forge collaborations with health departments, educational institutions, and NGOs, and engage community members in the planning process.

There should be trial installation, beginning with pilot locations to gather feedback and refine operations. Launch campaigns to raise awareness and provide educational materials on product usage and disposal at the point of sale comes later, with an institute of maintenance schedule for cleanliness, functionality, and restocking, with regular checks for mechanical and hygiene standards. The performances (sales data and user feedback) of the vending machines should also be monitored to evaluate effectiveness and adjust product offerings and locations accordingly.

Creating a channel for user feedback to inform continuous improvement is necessary. If all worked, developing an expansion plan based on initial success, and aiming for a self-funding model to ensure long-term project viability becomes the new goal.

This streamlined plan is designed to improve the availability and affordability of menstrual hygiene products while fostering an informed and supportive environment for menstrual health management.

4. Health Education

Several countries and regions have implemented policies that emphasize or mandate education on menstruation to varying degrees. For example, the UK government announced that all state-funded schools must provide age-appropriate Relationship and Sex Education (RSE), which includes menstrual education in 2019 [10].

The initiative's educational component is designed to enhance understanding and knowledge regarding menstrual health. It includes comprehensive information on the biological aspects of menstruation and hygiene practices. Gender-related knowledge on menstruation should also be addressed properly. The variety of sanitary products available, how to choose them accordingly, and the correct usage techniques. Proper disposal of menstrual products to prevent infections and maintain personal hygiene should also be covered.

It is imperative to recognize and address the social disparities that affect access to menstrual health education and resources. Some targeted approaches are proposed to ensure inclusivity and effectiveness, such as menstrual health education integrated into school health programs, aiming to normalize discussions and provide age-appropriate information [11]. Public spaces are leveraged for awareness campaigns through visual displays and community health events, ensuring that menstrual health education is accessible to a broader audience [12]. Workplace wellness programs are enhanced through collaborations with businesses to include menstrual health awareness, highlighting its impact on overall health and productivity. Online platforms are utilized to share educational content and foster interactive discussions, increasing the reach and engagement of menstrual health education. Local health departments and NGOs are partnered with to conduct outreach activities, educating community members about the benefits of menstrual health management and the availability of resources. Vending machines are equipped with educational leaflets and QR codes linking to online resources, providing on-the-spot information and further reading on menstrual health and product usage.

These educational and awareness-raising activities are designed to be inclusive, aiming to reduce stigma, improve knowledge, and promote the responsible use of sanitary products across different demographic segments. A multifaceted approach ensures a supportive environment conducive to better menstrual health management.

5. Community Intervention

The distribution of free menstrual products inside communities should follow these steps, while community members are encouraged to participate in the implementation of the program, including volunteer recruitment and management.

First, survey the number of female residents in the community and their menstrual cycles to estimate the number of menstrual products needed each month. Understand the needs of women of different ages in the community, including adolescents, adult women, and menopausal women. Then, determine the budget, including the cost of purchasing menstrual supplies and other costs that may be incurred during distribution; choose the type of menstrual products, such as pads, tampons, menstrual cups, etc., and consider environmental protection and sustainability. For instance, to estimate the cost of a 400-person community menstrual supply distribution program assuming that 400 women in the community need menstrual products within an average of 5 days of menstruating and that 5 sanitary napkins are used daily. The average cost of each sanitary napkin is 1 RMB. The total monthly cost of sanitary napkins in the community is 10,000 RMB. Considering the transportation and storage costs are around 10% of the total cost, and publicity, education costs, volunteer or staff subsidy, and emergency reserve, the total cost could be around 10,000 + 1,000 + 500 + 1,000 + 500 = 13,000RMB.

Look for possible sponsors or partners, such as NGOs, charities, or businesses, to support the program. And develop a publicity plan to raise awareness of the program among community members through community announcements, social media, posters, etc. Educate community members about menstrual health and proper use of menstrual products. Set up fixed distribution points, such as community centers, schools, or health centers.

Feedback should be collected regularly through WeChat, e-mail, or hotlines, evaluate the effectiveness of the distribution plan, and make adjustments based on the feedback. Schemes for unexpected events should be planned beforehand, such as supply chain disruptions or sudden increases in demand.

6. PPP and NGOs

In China, a collective effort is being made to combat the issue of menstrual poverty, with various organizations and individuals stepping forward to take action. One such initiative is GLEAM, a charity founded by high school students Hong Mengxi and Tang Zixin from Beijing Haidian Kaiwen School. Through a successful charity sale, they managed to raise funds that enabled them to donate sanitary pads to 80 girls from Liangshan Middle School in Xinhuang County, Hunan Province [3]. This direct support not only provides immediate relief but also raises awareness about the issue.

Building upon such individual efforts, several public welfare projects are contributing to the cause. These include the "Menstrual Peace Initiative" and the sanitary pad mutual aid box program by "Give Her Peers," the "Spring Willow Program" by Rende Foundation aimed at left-behind girls, and the "White Shell Program" by UU Public Welfare. These projects are united in their focus on education, the provision of hygiene products, and the promotion of gender equality, which are essential components in the fight against menstrual poverty.

The advantage of this collaborative approach is that it brings together the innovative capabilities and resources of the private sector with the deep community knowledge of non-governmental organizations (NGOs). This synergy allows for the development of comprehensive solutions that can effectively address the multifaceted nature of menstrual poverty.

However, this collaboration also faces challenges, primarily the potential misalignment of goals and values among different partners. To overcome this, it is crucial to establish effective communication channels and cooperative frameworks that ensure all stakeholders are working towards the same objectives.

Companies have a significant role to play in supporting these initiatives. They can provide financial support, donate products, engage in community education programs, and encourage employee participation in volunteer activities. Moreover, businesses within the sanitary product industry have the unique opportunity to introduce biodegradable menstrual products, which can help reduce the environmental impact of menstrual hygiene management. Additionally, these companies can leverage social media to promote menstrual health awareness, thereby increasing public consciousness and contributing to a broader societal shift toward recognizing and addressing menstrual poverty.

The fight against menstrual poverty in China is a multifaceted effort that requires the combined strengths of individuals, organizations, and corporations. By working together and addressing the challenges of collaboration, these entities can create a significant impact and work towards a more equitable and sustainable solution to this pressing social issue.

7. Economic Empowerment

7.1. Promoting Women's Economic Independence

According to UN Women's Strategy paper, economic empowerment enhances women's economic agency, autonomy, and well-being. When women are financially independent, they are more likely to have access to education and employment opportunities and are less dependent on family or social traditions [12]. This suggests that financial independence is a key factor for women to achieve self-worth and improve their quality of life, helping to reduce menstrual poverty.

Financial independence can be achieved through education, job training, microfinance, and entrepreneurship mentoring. For example, by increasing women's visibility and participation in the labor market, their economic opportunities can be increased. This not only helps to upgrade their personal skills and business capabilities but also helps women develop new ways of living through supportive measures implemented by policymakers and social organizations.

7.2. Support Entrepreneurship and Employment Opportunities

Provide education and training programs for rural women to enhance their entrepreneurial skills and employability. This includes basic education, vocational skills training, and business management courses.

China has implemented several education and training programs for rural women aimed at improving vocational skills and entrepreneurial capacity and enhancing employment and economic independence. The projects include vocational skills training, secondary vocational education, tertiary education, agricultural science and technology training, transfer employment training, and entrepreneurship training. The Government has emphasized the importance of training through the Opinions on Strengthening Vocational Training to Promote Employment and achieve employment for every trainee [13].

These programs have not only improved rural women's skills, but also opened up more opportunities for them to find jobs and start businesses, and promoted rural economic development and social progress. To increase participation, relevant departments need to strengthen publicity, recognize the importance of training, and carry out diversified training according to needs.

To ensure the training effect, local education, and women's federation organizations need to cooperate, carefully organize, supervise and manage, and formulate an assessment and evaluation mechanism to improve the quality of training.

Set up special funds or provide low-interest loans to help rural women get the initial capital they need to start a business. This reduces their financial risk and encourages them to try new business opportunities.

According to the Notice on Improving the Financial Discount Interest Policy for Small Guaranteed Loans to Promote Women's Entrepreneurship and Employment jointly issued by the Ministry of Finance and others, the maximum amount of newly issued small guaranteed loans for women is increased to 80,000 yuan, and the maximum amount of loans for qualified women who are jointly operated and organized to work can reach 100,000 yuan. The policy extended the coverage of the loan policy to rural women, relying on women's federations to organize the loan work, simplifying the loan procedures, and improving the approval efficiency [14].

Rural women are encouraged to join or establish cooperatives to gain better market information, technical support, and sales channels through collective power.

Women's Series Loan in Shandong Province: This initiative includes various loan products tailored to support women's entrepreneurship, including cooperative efforts. The program aims to provide financial support for women to start or expand their businesses, often in a cooperative setting, thereby leveraging collective strength to access better market information and technical support [15].

Guide market research, product positioning, and marketing strategies to help rural women better understand market needs and improve the market competitiveness of their products.

Health checks, insurance, and retirement benefits are provided to ensure the health and welfare of rural women, for instance, the Two Cancers Screening Project is a national health program in China that focuses on providing free cervical and breast cancer screenings for rural women. The program aims to detect these cancers early, when they are more treatable, and to improve the overall health of rural women [5]. New Rural Cooperative Medical System (NRCMS) covers medical expenses, reducing the financial burden on rural women. The New Rural Pension Scheme (NRPS) is designed to provide a basic pension for rural residents, ensuring that women have a source of income during their retirement years.

8. Cultural and Social Change

8.1. Breaking Cultural Taboos

Menstruation is considered taboo in many societies and cultures and is not easy to discuss openly. In some parts of Asia, menstruation is considered impure and associated with shame and filth. Women may experience discrimination and exclusion during menstruation, such as being barred from participating in religious activities or family rituals.

Adopt gender-neutral language in all public health communications, education materials, and medical consultations related to menstruation. Use terms such as "menstruators" instead of "women" to be more inclusive of all individuals who experience menstruation.

Media plays a pivotal role in shaping public perception and can be a powerful ally in redefining societal attitudes towards menstrual health. A strategic approach is essential to harness this influence effectively, beginning with a clear understanding of the target audience. Identifying the audience allows for designing messages that resonate with their experiences and values, fostering a deeper connection and understanding.

With the audience in focus, the next step is to develop a core message that not only asserts the fundamental right to menstrual health but also illuminates the wider social implications of menstrual poverty. This message must be clear, consistent, and compelling, capable of driving home the importance of the issue at hand. The power of this message is amplified when disseminated through a variety of channels, ensuring it reaches the widest possible audience. Television, radio, social media, billboards, and print media all play a part in spreading awareness and educating the public on the importance of menstrual health.

However, true engagement is achieved when the audience is invited to participate in the conversation. Interactive activities such as online discussions, social media campaigns, and public events provide platforms for dialogue, shared experiences, and collective learning, deepening the impact of the campaign. As the campaign unfolds, it's crucial to assess its effectiveness continuously. Gathering audience feedback, monitoring behavioral changes, and evaluating the campaign's reach provide valuable insights into its success and areas for improvement. To extend the campaign's reach and impact, forming partnerships with government agencies, NGOs, educational institutions, businesses, and community organizations is vital. These collaborations lend additional voices to the cause, broadening the message's influence and ensuring it resonates across various sectors of society.

Throughout this process, cultural sensitivity must be paramount. Promotional materials and messages should be crafted with respect and adapted to different cultural and social contexts, ensuring inclusivity and respect for diversity. Recognizing that social change is not achieved overnight, it's important to sustain the campaign over time. Ongoing efforts are necessary to instill long-term shifts in societal attitudes and behaviors, emphasizing the campaign's longevity and commitment. Underpinning the campaign with robust research and data is key to its credibility. Evidence-based communication strengthens the persuasive power of the message, lending it authenticity and trustworthiness.

Finally, establishing a mechanism for collecting and analyzing audience feedback is essential for the campaign's evolution. This feedback loop allows for continuous adjustments and improvements to the communication strategy, ensuring its ongoing relevance and effectiveness. By following this logical progression—from audience identification to feedback integration—the media can effectively champion the cause of menstrual health, driving societal change and advocating for a more informed and inclusive dialogue.

Implement comprehensive sexuality education in schools that includes information on menstruation for all students, regardless of gender identity. This education should emphasize the biological, psychological, and social aspects of menstruation.

Ensure that menstrual products are available in all restrooms, including gender-neutral facilities. Advocate for the stocking of a variety of products that cater to different needs and preferences.

Provide training for healthcare professionals to better understand the unique needs and experiences of transgender and non-binary menstruators. This includes education on gender-affirming treatments and menstrual management options.

Promote and support research into the experiences and needs of transgender and non-binary menstruators. Ensure that data collection includes gender identity to better understand and address the specific challenges faced by different groups.

Review and amend legislation to prevent discrimination based on gender identity in the context of menstruation. This includes laws related to healthcare, education, and workplace accommodations. The Affordable Care Act (ACA) prohibits discrimination based on sex, which is interpreted to include gender identity. This means that healthcare providers cannot refuse service to transgender or non-binary individuals.

Engage with transgender, non-binary, and LGBTQ+ communities to understand their experiences and needs better. Use these insights to inform policy development and service provision.

Launch public awareness campaigns to challenge stigma, break taboos, and foster a culture of inclusivity around menstruation. Highlight the experiences of transgender and non-binary menstruators to promote understanding and empathy.

8.2. Promote Women's Empowerment

Women's empowerment is the promotion of women's power and influence in all areas so that they can make their own choices, control their own lives and bodies, and participate fully in social, economic, and political activities. It should be the parallel goal of solving period poverty.

Empowerment enables women to achieve economic independence. Women's empowerment can help break social and cultural taboos around menstruation, promote more open dialogue, and reduce stigma and misconceptions about menstruation. Empowerment can increase women's sense of self-efficacy and make them more confident to seek help and resources in the face of menstrual poverty. Empowered women are more likely to be involved in their communities to provide support and resources to other women in tackling menstrual poverty. Women's empowerment contributes to improved overall health. Participate in developing and implementing sustainable solutions, such as promoting reusable hygiene products.

Female empowerment has a positive impact on the next generation, and through the power of education and role models, menstruation can be changed in the way it is perceived and dealt with, reducing the perpetuation of menstrual poverty.

Through these pathways, women's empowerment can not only directly address menstrual poverty, but also indirectly promote long-term investment and attention in menstrual health and hygiene by elevating women's social status and economic empowerment.

9. Conclusion

This study unveils the significant impact of menstrual poverty in rural China, hindering women's education, economic participation, mental health, and social well-being. Addressing menstrual poverty requires a holistic approach involving policy reforms, education, community support, and private-sector engagement.

Existing policies inadequately address menstrual poverty, lacking consideration for rural needs. Strengthening public health policies, menstrual hygiene infrastructure, and educational initiatives is essential to combat social taboos and stigmas.

Some recommended policies in case of raising menstrual equity, such as advocating for reduced taxes on menstrual products and providing free products to low-income families and schools; enhancing menstrual health infrastructure, especially in rural areas; promote comprehensive sex education and menstrual health courses. Other smaller interventions working alongside include implementing distribution programs and educating communities on menstrual hygiene; encouraging private sector involvement through partnerships and innovative solutions; and supporting economic independence for rural women through entrepreneurship and employment opportunities. Overall, promoting gender equality and women's empowerment is a fundamental goal of achieving menstrual equity.

Further research should improve on expanding sample diversity, with a combination of qualitative and quantitative methods. Longitudinal research will help track the impact of interventions over time and assess the long-term effects of menstrual poverty on affected individuals and communities. Regular policy evaluation is essential to ensure that measures taken to address menstrual poverty are effective and to identify areas for improvement.