Map the System: Menstrual Inequity in the United States

On 15-17 June 2020, the Skoll Centre’s Map the System Competition held its Global Final virtually. The team from University of Illinois Urbana-Champaign competed against 30 other finalists from institutions around the world at the event, coming in second place in the competition. Team members Angela, Ajaita and Jiho tell us their key learnings from taking part, and how they mapped the system to explore menstrual inequity in the United States.

Choosing Our Topic

We were originally nervous about this topic, unsure of how much information we’d find on menstrual inequity, especially for such an economically privileged country like the United States. Menstrual inequity is often focused in regions within the Global South, such as Kenya and India, but its debilitating consequences affect menstruators from nearly all nations and cultural backgrounds.

Our team is composed of menstruators from across the United States, from California to Illinois to New Jersey. However, we all shared something in common: we were menstruators and people of color who came to the table with stories. Ajaita was diagnosed with hormonal imbalance after four consecutive weeks of menstruating. Jiho’s sister thought she was dying when she got her first period, as she grew up as the oldest daughter in a family that didn’t talk about periods openly. On a happier note, Angela’s father was very supportive and helped with numerous stains around the house, but she soon realized her experience was unique.

We are lucky to say that we are among the more privileged menstruators in our country, but there are millions who face regular in access to clean menstrual products; stigma from peers, family members, and general society; as well as systemic power abuses that maintain sexist and harmful practices. Notably, we were shocked by the treatment of incarcerated individuals, trans and intersex menstruators, and the persistent ignorance by our government.

Learning Systems Thinking

The people we interviewed were especially receptive and eager in teaching us more about the menstrual justice space, and we can’t thank them enough for their help and passionate activism, even through this pandemic. A special shout out to our mentor, Valeri Werpetinski, who not only encouraged us to pursue this topic, but also consistently believed in our team (with several hour long sessions of constructive feedback and advice).

However, systems thinking was a completely new territory for us to explore, and our initial and final iterations looked vastly different from each other. Our campus presentation had strong storytelling components, but our focus on individual stakeholders and institutions caused a disconnect within the visual map. After researching systems-thinking tools, we realized that the information we compiled needed to be presented with more depth and complexity. Our final iteration for the global competition reflects this mind-set change, as we seeked to deliver a holistic view of menstrual inequity and its tangential systems.

Systems thinking has taught us to dig beyond the surface. Breaking down each entrenched aspect of this intimidatingly enormous issue became empowering as we learned that by dismantling one system, we could impact and help dismantle others. By deepening our understanding of the movement, we learned to stand with stakeholders and to view them as people who are stuck in cycles driven by an unjust system. Instead of researchers looking in from the outside, we became active members within the space.

What We’re Doing Now

This project has allowed us to access an incredibly welcoming space, with all of us joining the nonprofit Operation Period. While funding product donations and spreading awareness, OP has also taken a de-colonization and abolitionist approach to tackle menstrual injustice effectively. Ajaita, as Co-Art Director, is currently working on projects to spread awareness across the country. Jiho, as Podcast Producer, is lifting voices from different spaces in the movement. Angela, as Education Director, is updating the onboarding and shared curriculum to reflect their systemic approach. Through this, we aim to keep educating ourselves while transitioning our Map the System project onto our own independent website and resource to menstrual systems.

We’re thankful for all the support we’ve received, and for the opportunities given to us by Map the System. We hope you’ll join us in our fight against menstrual inequity.

There Will Be Blood Team

(Angela, Ajaita, and Jiho)

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Map the System: Using Systems Science to Advance Health Equity in Tobacco Control

On 15-17 June 2020, the Skoll Centre’s Map the System Competition held its Global Final virtually. The team from The University of North Carolina at Chapel Hill competed against 30 other finalists from institutions around the world at the event, coming in third place in the competition. Team members Meghan O’Leary, Paige Logan, Sarah Mills, Shelley Golden and Kristen Hassmiller Lich tell us how they mapped the system to explore inequities in tobacco control.

Smoking rates have declined considerably over the last five decades in the United States. However, this progress has not been shared equally. Many lower-income and racial/ethnic minority populations are more likely to smoke than their counterparts and disproportionately shoulder the burden of tobacco-related disease.

We created a team focused on understanding socioeconomic and racial/ethnic disparities in smoking from a systems perspective. Members of our team represent the fields of health behavior, health policy, and systems science. Building on these backgrounds, we developed a model that captures the multilevel factors affecting smoking. Processes of marginalization and segregation, as well as employment and housing factors that may produce financial strain, are included as key contributors to smoking in our model. By documenting these structural reasons for smoking disparities and lived experiences of people of color and lower-income groups, we hope our model can help to effectively engage communities and relevant stakeholders and to design tobacco control policies and programs capable of reducing smoking in priority populations.

Developing our model

Our model of smoking is informed by tobacco control literature and interviews with key stakeholders. We consulted prior research to identify factors associated with smoking. This included a close review of 12 prior smoking models – none of which addressed the specific factors contributing to higher smoking rates in priority populations. We turned to fundamental cause and social stress theories to identify these root causes of smoking among racial/ethnic minorities and lower-income groups.

We shared a model draft with nine stakeholders, who provided insightful feedback about our model, allowing us to consider new factors that should be included and challenging us to carefully consider the relationships between variables. They provided the perspectives of smokers, mental health professionals, health equity advocates, and community-based organizations.

Our Smoking Model

  • Green = individual-level factors associated with smoking
  • Blue = environmental-level factors associated with smoking
  • Red = root causes of smoking among racial/ethnic minority and low-income populations
  • + indicates the variables move in the same direction (e.g., as stress increases, tobacco use increases)
  • – indicates the variables move in the opposite direction (e.g., as access to cessation services increases, tobacco use decreases)

Policy Implications

We applied our model to tobacco control policies designed to improve equity in tobacco control, revealing how the policies are intended to address disparities, as well as their potential unintended effects that may sustain or worsen disparities. For example, smoke-free public housing aims to lower smoking among public housing residents by creating more smoke-free homes and reducing pro-smoking norms. Yet, violation of this policy may result in financial strain and/or housing instability, increasing stress and reducing feelings of controls, which can lead to increased smoking. The figures below illustrate these intended and unintended effects.

Text Box: Smoke-free Air Policy
Figure 1. Expected Impacts of the Smoke-free Air Policy

Reinforcing loops in the model are indicated with an ‘R’ and represent relationships that will continue to grow, or reinforce, over time.

Figure 2. Unintended Impacts of the Smoke-free Air Policy

We identified two other disparities-focused policies with potential unintended consequences per our model:

  • A menthol ban intends to reduce smoking among those who prefer menthol cigarettes. However, targeted marketing of other tobacco products is still possible through segregation and discrimination.
  • Minimum price laws (MPLs) enact the largest price increases on the least expensive tobacco products. While expected to reduce smoking by raising prices, this policy may unintentionally increase financial strain and stress and reduce feelings of control.

Our Recommendations

1. Use a health equity lens

Tobacco control efforts often focus on reducing smoking at the population level, but to ensure equitable outcomes, attention to priority populations is needed. Being intentional and focusing on how systemic racism and other structural factors permeate the model pathways and contribute to smoking disparities is critical. Future tobacco control efforts must acknowledge and address these lived experiences of communities.

2. Consider the intended and unintended consequences of tobacco control policies and programs

Well-intentioned efforts to lower smoking in priority populations can have unintentional and even counteractive effects. Consideration of these adverse outcomes upfront, as well as ongoing evaluation of policies and programs, can help to identify, react to, and address these unwanted effects.

3. Engage diverse types of stakeholders in tobacco control efforts

Additional voices are needed to represent the needs and perspectives of priority populations. We recommend engaging smokers, retailers, housing officials, law enforcement, social service agencies, mental health practitioners, and community-based organizations. Partnering with local communities can help to identify other relevant stakeholders.

Next Steps

Map the System provided a platform to present our model of smoking and receive feedback from other systems thinkers working on similarly complex issues. We value the information learned and are committed to continuing this work. We are currently conducting additional stakeholder interviews. We hope to build confidence in our model by testing some of the relationships between variables through future studies, and use our model to facilitate collaborative discussions about tobacco control in diverse populations.