Developing PEEN, a rights-based national menstrual health program for Iran: a multiphase evidence-synthesis and expert-consensus study

Menstrual health is increasingly recognized as a matter of public health, gender equity, and human rights. However, many menstrual health policies remain fragmented or product-centered and insufficiently address legal recognition, stigma, menstrual literacy, equity, and multisectoral governance. In Iran, no unified national menstrual health program currently exists. This study aimed to develop and methodologically appraise a rights-based and equity-oriented National Menstrual Health Management Program for Iran, named PEEN. This study used a multiphase qualitative evidence-synthesis and expert-consensus design. Qualitative content analysis was conducted using 26 individual interviews, including 15 menstruators and 11 key informants, and seven focus group discussions involving 31 participants. A systematic review of global menstrual health policies and programs was used to identify international policy domains and implementation gaps. Qualitative findings and global evidence were mapped and synthesized to develop the preliminary PEEN draft. The program was refined through the Nominal Group Technique with seven expert panel members and three research facilitators. Methodological quality appraisal was conducted using the AGREE II instrument by three independent experts. Qualitative analysis generated 2,776 initial codes, which were abstracted into five themes: recognition of menstruation as a right; menstrual justice, reproductive health, and sustainable development; empowerment in menstrual management; normalization from humiliation to dignity; and moving forward through the development of laws. The systematic review identified 27 eligible documents from 832 records. Integration of local and global evidence resulted in four interdependent PEEN components: Policy, Empowerment, Equity, and Normalization. Expert consensus clarified that PEEN should be presented as national program components rather than sequential steps. All retained components met the predefined 70% consensus threshold, and experts reached full agreement on their necessity, applicability, and scientific soundness. AGREE II domain scores ranged from 83% to 100%, supporting the methodological quality and reporting transparency of the program-development process. PEEN proposes a national, rights-based, and equity-oriented framework for institutionalizing menstrual health within reproductive health, education, labor, legal, and social policy systems in Iran. As the program has not yet been implemented, pilot testing and prospective evaluation are required to assess its feasibility, acceptability, cost, implementation requirements, and potential effects. Menstrual health is an important part of everyday life, but it is often ignored, misunderstood, or surrounded by shame and silence. Many women and girls face difficulties during menstruation, including lack of information, stigma, limited access to products, and absence of supportive laws or services. These challenges can affect health, education, work, and quality of life. In Iran, although some health and educational activities exist, there is no single national program that clearly addresses menstrual health as a right or supports women and girls in a coordinated way. To respond to this gap, we developed the National Menstrual Health Management Program (PEEN). The program was created in three main steps. First, we listened to the experiences of women and girls and to experts such as health professionals, legal specialists, and policymakers. Second, we reviewed menstrual health programs and policies from other countries. Third, national experts reviewed and improved the program to ensure that it fits the cultural and social context of Iran. PEEN goes beyond providing menstrual products alone. It focuses on four connected areas: supportive laws and policies, education and empowerment, fairness and access for vulnerable groups, and reducing stigma through positive social and cultural change. PEEN offers a national plan to help menstruators manage menstruation safely and with dignity. By recognizing menstrual health as a rights and equity issue, the program may support better health, gender equality, and fuller participation in society.