{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T03:01:23Z","timestamp":1787022083292,"version":"build-2736575974"},"reference-count":52,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2021,6,23]],"date-time":"2021-06-23T00:00:00Z","timestamp":1624406400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"The Sid and Helaine Lerner MHM Faculty Support Fund"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:p>Access to safe, clean water and sanitation is globally recognized as essential for public health. Public toilets should be accessible to all members of a society, without social or physical barriers preventing usage. A public toilet facility\u2019s design and upkeep should offer privacy and safety, ensure cleanliness, provide required sanitation-related resources, and be gender equitable, including enabling comfortable and safe management of menstruation. Menstrual hygiene management (MHM) refers to the need to ensure that girls, women and all people who menstruate have access to clean menstrual products, privacy to change the materials as often as needed, soap and water for washing the body as required, and access to facilities to dispose of used materials. Challenges around menstruation faced by people experiencing homelessness, which tend to be greater than those facing the general population, include inadequate toilet and bathing facilities, affordability issues around menstrual products, and menstrual stigma. Public toilets are a vital resource for managing menstruation, particularly for vulnerable populations without reliable access to private, safe, and clean spaces and menstrual products. This mixed-methods study sought to: 1) understand the lived experiences of MHM among people experiencing homelessness in New York City with respect to public toilets; 2) describe general and MHM-related characteristics of public toilets in high need areas of Manhattan and analyze their interrelationships; and 3) examine the associations among neighborhood-level demographics and the public toilet characteristics in those areas. Qualitative methods included key informant interviews (n = 15) and in-depth interviews (n = 22) with people with experience living on the street or in shelters, which were analyzed using Malterud\u2019s \u2018systematic text condensation\u2019 for thematic cross-case analysis. Quantitative methods included audits and analyses of public toilet facilities (n = 25) using traditional statistics (e.g., Spearman\u2019s correlations) and spatial analyses (e.g., proximity buffers). Qualitative findings suggest cleanliness, access to restrooms, and availability of resources are critical issues for the participants or prospective users. Quantitative analyses revealed insufficiently provided, maintained, and resourced public toilets for managing menstruation in high-needs areas. Findings also suggest that toilets with more MHM-related resource availability, such as menstrual products and toilet stall disposal bins, were more difficult to access. Neighborhood-level characteristics showed a potential environmental injustice, as areas characterized by higher socioeconomic status are associated with more access to MHM-specific resources in public restrooms, as well as better overall quality.<\/jats:p>","DOI":"10.1371\/journal.pone.0252946","type":"journal-article","created":{"date-parts":[[2021,6,23]],"date-time":"2021-06-23T13:24:33Z","timestamp":1624454673000},"page":"e0252946","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":56,"title":["Public restrooms, periods, and people experiencing homelessness: An assessment of public toilets in high needs areas of Manhattan, New York"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9398-2386","authenticated-orcid":true,"given":"Andrew R.","family":"Maroko","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kim","family":"Hopper","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Caitlin","family":"Gruer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4939-770X","authenticated-orcid":true,"given":"Maayan","family":"Jaffe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erica","family":"Zhen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marni","family":"Sommer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,6,23]]},"reference":[{"issue":"11","key":"pone.0252946.ref001","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pmed.1000367","article-title":"Hygiene, Sanitation, and Water: Forgotten Foundations of Health","volume":"7","author":"J Bartram","year":"2010","journal-title":"PLoS Medicine"},{"key":"pone.0252946.ref002","author":"G Hutton","year":"2017","journal-title":"Water Supply, Sanitation, and Hygiene"},{"issue":"5","key":"pone.0252946.ref003","first-page":"537","article-title":"Estimating the Burden of Disease from Water, Sanitation and Hygiene at Global Level","volume":"110","author":"A Pr\u00fcss","year":"2002","journal-title":"Environmental Health Perspectives"},{"key":"pone.0252946.ref004","first-page":"e1","article-title":"Water and Sanitation in Urban America, 2017\u20132019","volume":"2020","author":"D Capone","journal-title":"American Journal of Public Health"},{"issue":"11","key":"pone.0252946.ref005","doi-asserted-by":"crossref","first-page":"613","DOI":"10.1016\/j.puhe.2010.07.002","article-title":"Public toilets down the drain? Why privies are a public health concern","volume":"124","author":"R Stanwell-Smith","year":"2010","journal-title":"Public Health"},{"issue":"5","key":"pone.0252946.ref006","doi-asserted-by":"crossref","first-page":"505","DOI":"10.3828\/tpr.2016.35","article-title":"Taking women\u2019s bodily functions into account in urban planning and policy: Public toilets and menstruation","volume":"87","author":"C Greed","year":"2016","journal-title":"Town Planning Review"},{"key":"pone.0252946.ref007","doi-asserted-by":"crossref","unstructured":"Street P. Public Toilets: Determinant of the Progress of Civilization and Consciousness of Societies or a Necessary Evil? Advances in Human Factors in Architecture, Sustainable Urban Planning and Infrastructure: Proceedings of the AHFE 2019 International Conference on Human Factors in Architecture, Sustainable Urban Planning and Infrastructure. 966. Washington DC: Springer; 2019. p. 87.","DOI":"10.1007\/978-3-030-20151-7_9"},{"issue":"9","key":"pone.0252946.ref008","doi-asserted-by":"crossref","first-page":"1556","DOI":"10.2105\/AJPH.2013.301374","article-title":"Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls","volume":"103","author":"M Sommer","year":"2013","journal-title":"Am J Public Health"},{"issue":"6","key":"pone.0252946.ref009","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1007\/s11524-017-0189-3","article-title":"Physical, Social, and Political Inequities Constraining Girls\u2019 Menstrual Management at Schools in Informal Settlements of Nairobi, Kenya","volume":"94","author":"C Girod","year":"2017","journal-title":"Journal of Urban Health"},{"issue":"9","key":"pone.0252946.ref010","doi-asserted-by":"crossref","first-page":"1193","DOI":"10.3390\/w10091193","article-title":"Making the Case for a Female-Friendly Toilet","volume":"10","author":"M Schmitt","year":"2018","journal-title":"Water"},{"key":"pone.0252946.ref011","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1007\/s11199-011-0052-z","article-title":"The Menstrual Mark: Menstruation as Social Stigma","volume":"68","author":"I Johnston-Robledo","year":"2013","journal-title":"Sex Roles"},{"key":"pone.0252946.ref012","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1186\/1472-698X-11-7","article-title":"\u2019The girl with her period is the one to hang her head\u2019 Reflections on menstrual management among schoolgirls in rural Kenya","volume":"11","author":"SA McMahon","year":"2011","journal-title":"BMC international health and human rights"},{"issue":"4","key":"pone.0252946.ref013","doi-asserted-by":"crossref","first-page":"271","DOI":"10.1016\/j.jpag.2006.05.002","article-title":"Knowledge, attitudes, and consequences of menstrual health in urban adolescent females","volume":"19","author":"AM Houston","year":"2006","journal-title":"Journal of pediatric and adolescent gynecology"},{"issue":"6","key":"pone.0252946.ref014","doi-asserted-by":"crossref","first-page":"e026186","DOI":"10.1136\/bmjopen-2018-026186","article-title":"Productivity loss due to menstruation-related symptoms: a nationwide cross-sectional survey among 32 748 women","volume":"9","author":"ME Schoep","year":"2019","journal-title":"BMJ open"},{"key":"pone.0252946.ref015","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1186\/s12939-016-0379-8","article-title":"Managing menstruation in the workplace: an overlooked issue in low- and middle-income countries","volume":"15","author":"M Sommer","year":"2016","journal-title":"International journal for equity in health"},{"key":"pone.0252946.ref016","unstructured":"UNICEF. FAST FACTS: Nine things you didn\u2019t know about menstruation UNICEF: UNICEF; 2018 [Available from: https:\/\/www.unicef.org\/press-releases\/fast-facts-nine-things-you-didnt-know-about-menstruation."},{"key":"pone.0252946.ref017","author":"R Levit","year":"2017","journal-title":"Waiting and Menstruation: A Look at Homeless and At-Risk Women\u2019s Experiences"},{"issue":"2","key":"pone.0252946.ref018","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1097\/AOG.0000000000003060","article-title":"Unmet Menstrual Hygiene Needs Among Low-Income Women","volume":"133","author":"SA Kuhlmann","year":"2019","journal-title":"Obstetrics Gynecology"},{"key":"pone.0252946.ref019","first-page":"0242","article-title":"Reproductive Health of Homeless Adolescent Women in Seattle, Washington, USA Reproductive Health of Homeless Adolescent Women in Seattle, Washington, USA","author":"J Ensign","year":"2008","journal-title":"Women & Health"},{"key":"pone.0252946.ref020","author":"SL Durfor","year":"2015","journal-title":"Personal Hygiene Self-Management of Chronically Unsheltered Homeless Women"},{"key":"pone.0252946.ref021","author":"Coalition for the Homeless","year":"2019","journal-title":"Facts About Homelessness"},{"key":"pone.0252946.ref022","author":"NYC Department of Homeless Services","year":"2019","journal-title":"Stats and Reports"},{"key":"pone.0252946.ref023","doi-asserted-by":"crossref","first-page":"102431","DOI":"10.1016\/j.healthplace.2020.102431","article-title":"Menstruation and homelessness: Challenges faced living in shelters and on the street in New York City","volume":"66","author":"M Sommer","year":"2020","journal-title":"Health & Place"},{"issue":"6","key":"pone.0252946.ref024","doi-asserted-by":"crossref","first-page":"1441","DOI":"10.1111\/1475-6773.12171","article-title":"Access to care: remembering old lessons","volume":"37","author":"CG McLaughlin","year":"2002","journal-title":"Health services research"},{"issue":"2","key":"pone.0252946.ref025","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1097\/00005650-198102000-00001","article-title":"The concept of access: definition and relationship to consumer satisfaction","volume":"19","author":"R Penchansky","year":"1981","journal-title":"Med Care"},{"key":"pone.0252946.ref026","doi-asserted-by":"crossref","first-page":"E139","DOI":"10.5888\/pcd15.180344","article-title":"Occupational Groups and Environmental Justice: A Case Study in the Bronx, New York","volume":"15","author":"AR Maroko","year":"2018","journal-title":"Prev Chronic Dis."},{"key":"pone.0252946.ref027","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1016\/j.apgeog.2012.02.005","article-title":"Using air dispersion modeling and proximity analysis to assess chronic exposure to fine particulate matter and environmental justice in New York City","volume":"34","author":"AR Maroko","year":"2012","journal-title":"Applied Geography"},{"issue":"4","key":"pone.0252946.ref028","doi-asserted-by":"crossref","first-page":"551","DOI":"10.1177\/10780870122184993","article-title":"Environmental justice and southern California\u2019s \u2018\u2018riskscape\u201d\u2014the distribution of air toxics exposures and health risks among diverse communities","volume":"36","author":"R Morello-Frosch","year":"2001","journal-title":"Urban Affairs Review"},{"issue":"11\u201312","key":"pone.0252946.ref029","doi-asserted-by":"crossref","first-page":"1325","DOI":"10.1289\/ehp.1206337","article-title":"Air pollution and individual and neighborhood socioeconomic status: evidence from the multi-ethnic study of atherosclerosis (MESA).(Research)","volume":"121","author":"A Hajat","year":"2013","journal-title":"Environmental Health Perspectives"},{"issue":"3","key":"pone.0252946.ref030","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1057\/jphp.2013.19","article-title":"Overweight and obesity: can we reconcile evidence about supermarkets and fast food retailers for public health policy?","volume":"34","author":"D Viola","year":"2013","journal-title":"J Public Health Policy"},{"issue":"3","key":"pone.0252946.ref031","doi-asserted-by":"crossref","first-page":"412","DOI":"10.1007\/s11524-012-9782-7","article-title":"More than just an eyesore: local insights and solutions on vacant land and urban health","volume":"90","author":"E Garvin","year":"2013","journal-title":"Journal of urban health: bulletin of the New York Academy of Medicine"},{"issue":"11","key":"pone.0252946.ref032","doi-asserted-by":"crossref","first-page":"115003","DOI":"10.1088\/1748-9326\/10\/11\/115003","article-title":"\u2018At-risk\u2019 places: inequities in the distribution of environmental stressors and prescription rates of mental health medications in Glasgow, Scotland","volume":"10","author":"J Maantay","year":"2015","journal-title":"Environmental Research Letters"},{"issue":"6","key":"pone.0252946.ref033","article-title":"The collapse of place: derelict land, deprivation, and health inequality in Glasgow, Scotland","volume":"1","author":"JA Maantay","year":"2013","journal-title":"Cities and the environment (CATE)"},{"issue":"4","key":"pone.0252946.ref034","first-page":"353","article-title":"Taking the High Line: elevated parks, transforming neighbourhoods, and the ever-changing relationship between the urban and nature","volume":"9","author":"H Littke","year":"2016","journal-title":"Journal of Urbanism: International Research on Placemaking and Urban Sustainability"},{"issue":"1","key":"pone.0252946.ref035","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.amepre.2007.09.030","article-title":"Income and racial disparities in access to public parks and private recreation facilities","volume":"34","author":"L Abercrombie","year":"2008","journal-title":"American Journal of Preventive Medicine"},{"issue":"52","key":"pone.0252946.ref036","doi-asserted-by":"crossref","first-page":"26139","DOI":"10.1073\/pnas.1920490117","article-title":"Opinion: Why green \u201cclimate gentrification\u201d threatens poor and vulnerable populations","volume":"116","author":"I Anguelovski","year":"2019","journal-title":"Proceedings of the National Academy of Sciences"},{"key":"pone.0252946.ref037","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1016\/j.landurbplan.2016.05.017","article-title":"A complex landscape of inequity in access to urban parks: A literature review","volume":"153","author":"A Rigolon","year":"2016","journal-title":"Landscape and Urban Planning"},{"key":"pone.0252946.ref038","article-title":"Unreliable and Difficult-to-Access Food for Those in Need: A Qualitative and Quantitative Study of Urban Food Pantries","author":"ZA Ginsburg","year":"2018","journal-title":"J Community Health"},{"key":"pone.0252946.ref039","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.appet.2015.02.034","article-title":"Urban farmers\u2019 markets: accessibility, offerings, and produce variety, quality, and price compared to nearby stores","volume":"90","author":"SC Lucan","year":"2015","journal-title":"Appetite"},{"issue":"1","key":"pone.0252946.ref040","first-page":"15","article-title":"The hidden inequity in health care","volume":"10","author":"B Starfield","year":"2011","journal-title":"Intern"},{"issue":"2","key":"pone.0252946.ref041","first-page":"3","article-title":"The right to sutures: social epidemiology, human rights, and social justice","volume":"12","author":"S Venkatapuram","year":"2010","journal-title":"Health Hum Rights"},{"issue":"5","key":"pone.0252946.ref042","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1016\/S0167-6296(00)00050-3","article-title":"Equity in the delivery of health care in Europe and the US","volume":"19","author":"E van Doorslaer","year":"2000","journal-title":"Journal of Health Economics"},{"key":"pone.0252946.ref043","article-title":"Lack Of Bathrooms For Seattle\u2019s Homeless Counter To U.N. Standard","author":"N McNamara","year":"2019","journal-title":"Patch"},{"key":"pone.0252946.ref044","article-title":"Where Are Portable Toilets on City Streets?","author":"J Cowan","year":"2019","journal-title":"New York Times"},{"key":"pone.0252946.ref045","article-title":"Subway Bathrooms: Are They as Bad as You Think?","author":"A Newman","year":"2019","journal-title":"New York Times"},{"key":"pone.0252946.ref046","unstructured":"NYC Department of Homeless Services. HOPE 2020 2020 [Available from: https:\/\/www1.nyc.gov\/site\/dhs\/outreach\/hope.page."},{"key":"pone.0252946.ref047","author":"UNICEF, WaterAid, WSUP.","year":"2018","journal-title":"Female-friendly public and community toilets: a guide for planners and decision makers."},{"key":"pone.0252946.ref048","volume-title":"IPUMS National Historical Geographic Information System: Version 14.0 [Database]","author":"S Manson","year":"2019"},{"key":"pone.0252946.ref049","first-page":"1","article-title":"Improving Population Mapping and Exposure Assessment: Three-Dimensional Dasymetric Disaggregation in New York City and S\u00e3o Paulo, Brazil","author":"A Maroko","year":"2019","journal-title":"Papers in Applied Geography"},{"issue":"3","key":"pone.0252946.ref050","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1559\/152304006779077309","article-title":"Intelligent Dasymetric Mapping and Its Application to Areal Interpolation","volume":"33","author":"T Hultgren","year":"2006","journal-title":"Cartography and Geographic Information Science"},{"issue":"2","key":"pone.0252946.ref051","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1559\/152304001782173727","article-title":"Dasymetric Mapping and Areal Interpolation: Implementation and Evaluation","volume":"28","author":"CL Eicher","year":"2001","journal-title":"Cartography and Geographic Information Science"},{"issue":"1","key":"pone.0252946.ref052","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1111\/0033-0124.10042","article-title":"Generating Surface Models of Population Using Dasymetric Mapping","volume":"55","author":"J Mennis","year":"2003","journal-title":"The Professional Geographer"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0252946","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,11,5]],"date-time":"2023-11-05T02:39:09Z","timestamp":1699151949000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0252946"}},"subtitle":[],"editor":[{"given":"Sean A.","family":"Kidd","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,6,23]]},"references-count":52,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2021,6,23]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0252946","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,23]]}}}