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Abstract

Introduction

Females are underrepresented in the expedition environment. There are no published studies exploring females’ concerns relating to their health in this environment. There is no guidance in key medical texts on preparing females during the pre-expedition phase. This study asked to what extent female-specific health concerns are a barrier and why.

Methods

This cross-sectional study used an electronic survey distributed to females aged 18 to 40 y. Individuals from both the expedition community and those with no related experience were invited to participate via WhatsApp and Posters in local workplaces. Questions explored attitudes around toilet facilities, period health (PH), and strategies females use to manage periods on expeditions.

Results

Two hundred and eighty-one individuals completed the survey. Lack of toilets is a barrier to participation in adventure tourism and expeditions (AT&E) for 24% of respondents. PH concerns were a barrier for 26%, and only 12% had no concerns with managing PH. Concerns regarding toilets or PH have stopped 11.4% from taking part in expeditions. When looking for information regarding PH and AT&E, 14% of participants were unable to find useful information, and only 10% of respondents felt that school education was adequate.

Conclusions

Female health concerns are a barrier to participation in AT&E, and currently, the expedition community and education are not equipping individuals to overcome those barriers. For >10% of participants, these barriers have caused them to miss life-affirming opportunities. Better pre-expedition resources are needed for females, and further research is needed across a wider age range, including perimenopausal and teenage populations.

Keywords

women's health expeditions mountaineering tourism menstruation period health

Introduction

In the United Kingdom, there is a high female drop-out from physical activity at puberty, amounting to a public health issue.¹ Reasons given for drop-out include worry about period health (PH), lack of female role models, breast pain, low confidence, and social norms portraying sport as for boys.¹ In 2018, only 1.5% of International Federation of Mountain Guides Associations certified guides were female.² Only 9% of UK Winter Mountain Leaders were female in 2017.³

Much research explores the physiology and psychology of the menstrual cycle, translating to training female athletes.⁴ Some aspects (eg, metabolic differences in the polar regions) of the female physiologic response do not differ from those of males in response to extreme environments,⁵ whereas other aspects (eg, the female metabolic response at altitude) do differ⁶ Social science investigates social constraints that influence females' participation in sport^3,7–9 but do not explore female health (FH) concerns.

Anthropologists agree that PH and FH issues remain taboo.⁴ In the United Kingdom, only 20% of females feel comfortable talking to a coach or teacher about female-specific issues⁸ despite open discussion being key to increased physical or mental performance.⁴ PH remains a social, psychological, and physical barrier to participation in sport for some females^1,4 Professional sport is only recently embracing a change of culture around PH.¹⁰ The impact of FH on participation in adventure tourism and expeditions (AT&E) is not known. Searches of PubMed and Google Scholar revealed a paucity of research on PH in remote or extreme environments, with only 1 relevant study published in the scientific literature. Doran⁹ explored social constraints and their impact as barriers to female participation on mountaineering holidays. The study did not explore the impact of FH as a barrier, and the mountaineering focus was narrow.

Broader searches provided insights from the military community. A recent literature review¹¹ summarized the knowledge and research needs regarding females in combat, but only 1 paragraph considered urinary and PH, concluding that adverse outcomes relating to these issues are “probably preventable.” Further research into PH was not recommended as an area for future research despite acknowledging earlier research recommending PH as an area for attention.

The Swedish Armed Forces recruitment campaign of 2018 to 2020¹² aimed to normalize periods and females’ bodies. The strategy behind the campaign recognized that “the more questions we address, the more we will lower the threshold for those who are thinking about enlisting.”^{12 (p11)} Campaign billboards asked the question, “Can I have my period in the field?” Placement of the advertisements were strategic to be seen by both genders, thereby normalizing discussion and management of periods while recognizing that individuals lack answers to these questions.

There are no published studies that document the opinions, ideas, or health concerns of females during AT&E. The literature search was widened to include the gray literature, plus social media, to ascertain what information and discussions were available to females. Some articles and videos were found from individuals who shared learning from their personal experiences.^13,14

Our experience as peer participants on expeditions, and working as expedition doctors, has highlighted gaps in female confidence and knowledge in relation to FH and PH during AT&E. Personal experience of attending teaching to healthcare professionals on these topics shows that little advice is given for expedition medics other than to pack period products in the medical kit. The Oxford Handbook of Expedition and Wilderness Medicine, second edition,¹⁵ and the Field Guide to Wilderness Medicine¹⁶ omit the words female, woman, menstruation, and period. Given that FH is not well covered by healthcare professionals, it is unlikely that expedition medics and guides are equipped to help females. A knowledge of the varied symptoms related to the menstrual cycle and how they might affect an individual's performance, what period products may specifically suit (or not) use in a specific environment or activity, and how to normalize discussions around PH to reduce the taboo nature of the topic are all education themes that are being promoted to sports coaches.¹ Increased knowledge may help medics and guides when they are advertisings for clients, providing predeparture briefings or to support females during an activity.

It is unclear whether FH concerns contribute to the underrepresentation of females in AT&E. Furthermore, it's unclear how the industry can support females because there's no documentation of current ideas, concerns, and expectations. Therefore, the research aims of this study were, first, to establish whether FH concerns are a barrier to participation in AT&E and, second, if PH does present a barrier, to understand the extent and reasons. In relation to the second study aim, it was hypothesized that younger females would have greater concerns regarding PH.¹

Methods

A quantitative survey methodology was used. The survey was designed to investigate themes identified from the literature search plus personal experience. Question themes were attitudes toward AT&E, concerns around toileting, ideas and concerns about managing PH, strategies used to manage periods during AT&E, and finally, sources of information used to help navigate PH during AT&E. Thirteen questions were replicated from Doran's study⁸ to compare baseline attitudes toward AT&E regarding social constraints.

The survey was anonymous, and there were no incentives to complete the survey. Before data collection, the survey was tested by 5 individuals. This provided an estimated time needed to complete the survey, which was quoted in the consent process. An information and consent form was embedded at the survey start.

Inclusion was limited to females (a person assigned female sex at birth or a person who identifies as female) aged 18 to 40 y. The consent form explained that some questions would only be applicable to individuals who do, or have, menstruated. Excluded were males <18 or >40 y of age. Females <18 y of age were omitted because of difficulties in obtaining ethical approval. Age 40 y was the upper limit to avoid confounding the study with the influence of perimenopausal symptoms. The average age of menopause is 51 y in the United Kingdom, and only 1% of females will have their menopause under the age of 40 y.¹⁷ Responses were sought from individuals who both had or had not participated in AT&E.

Ethical approval for the study was obtained via the “Low Risk Pathway” provided by the university’s scheme for “Overarching Ethics Certificate for Postgraduate Taught Masters Independent Research Projects of Low Risk Typology.” The questionnaire was created using Microsoft Forms and was distributed by (a) WhatsApp to personal contacts, (b) requesting personal contacts to forward the survey on to their contacts, (c) email and posters at workplaces (eg, a primary school and a large home furnishings retail store), (d) posters in the female toilets at a church, and (e) social media (ie, Instagram and Facebook). The school and retail store were chosen because they have a high proportion of female workers, and they are not linked to the AT&E industry. It was hoped that this would increase the proportion of respondents who had not participated in AT&E.

AT&E was defined at the start of the survey as any activity in a remote setting, where one night or more is spent sleeping in accommodation (of any type) without a plumbed in toilet and washing facilities. Activities could include hiking, trekking, cycling, climbing, sailing, kayaking, and horseback riding.

Responses were collected for 4 wk (May 2023), and then the data were downloaded into Microsoft Excel (v2305) for statistical analysis. A process of response-set checks screened for individual responses that were not completed correctly (eg, all responses for that individual being “Strongly agree”). Once the data had been sense checked, they were summarized in contingency tables.

Questions regarding social constraints were analyzed using the same method as Doran⁹ to give a weighted mean. The Likert categories were each given a value (Strongly agree=5; Agree=4; Neutral=3, etc), and this value was multiplied by the number of respondents who selected it. The sum of these was divided by the total number of respondents, giving a mean score for each question. A mean of 3 indicated neutrality in the sample, whereas 5 indicated strong agreement.

Descriptive statistics were used to display the results. χ² tests were used for subgroup analysis to compare the difference in concerns with PH between older and younger respondents. A threshold of P<0.01 was considered significant. Where χ² suggested a significant result, correlation graphs were drawn using Excel, and Spearman's rank correlation coefficient was calculated manually and checked using an online calculator.¹⁸

Results

The survey was completed by 281 participants. One participant was born male but identified as a female; the rest were born female. The age range was 18 to 40 y, with a median age of 32 (interquartile range, 6) y with a moderately negative skew (−0.5).

Baseline data regarding participants’ general attitudes toward AT&E were collected. AT&E was not appealing to 56 respondents (20%) compared with 196 respondents (69%), for whom it was. The remaining 10% were ambivalent. The majority (n=231; 82%) had previously taken part in AT&E.

The degree to which social constraints were a barrier to participation in AT&E showed a similar pattern to those in the population surveyed by Doran⁹ (Table 1). Concern about technical ability, not being good enough, feeling that their performance must be seen as good by the group, and fitness level were the four constraints where, on average, the group agreed it to be a barrier. This agreement was weak because the mean scores were 3.2, 3.2, 3.17, and 3.12, respectively.

Table 1.

How strongly females agree with social constraints as barriers to their participation in AT&E.

Statement	Mean	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree	Did not answer
I am worried about my technical ability for the task (eg, navigation, camping skills, sailing/climbing skills, etc).*	3.2	32	114	43	63	27	2
I feel I would not be “good enough.”*	3.2	45	106	30	63	36	1
Although I think I would feel proud if I completed the challenge, and had fun while doing so, I still feel that my performance needs to be seen as “good” by the rest of the group.*	3.17	31	117	42	52	39	0
I am worried about my fitness level.*	3.12	26	111	38	85	22	0
I feel unsafe in unfamiliar environments.*	2.83	17	73	70	85	35	2
People would be watching me.*	2.81	21	73	58	81	44	4
I think of myself as unadventurous.*	2.63	22	59	47	98	54	1
I would worry about being in the minority as a woman.*	2.63	14	79	35	83	59	1
They are portrayed as being scary, uncomfortable, and intimidating.*	2.53	11	58	43	123	45	1
The lack of (or guarantee of) female guides/instructors discourages me.*	2.51	10	52	66	94	58	1
They are portrayed as being an activity for men.*	2.41	8	54	55	107	56	1
The clothing that is needed for the activity is off-putting to me.*	2.19	8	35	48	96	90	4
These types of activities do not appeal to me.*	2.13	12	44	29	78	116	2
I did not enjoy PE at school, so I won’t like this activity either.*	2.03	11	26	39	86	117	2

AT&E, adventure tourism or expedition activity.

The social constraints marked “*” were identified in a previous study.⁸ The mean was calculated by assigning numbers to the Likert scale outcomes (strongly agree=5, agree=4, neutral=3, disagree=2, strongly disagree=1) and multiplying this by number of individuals who agreed with each statement and then dividing by the number of respondents (n=281). This methodological approach was informed by Doran.⁸ The constraints with a mean score of >3.1 are constraints that the surveyed group agreed with more than not.

The first aim was to explore whether FH was a barrier to participation in AT&E. In all, 24% of participants (n=67) felt that a lack of toilets had or would stop them from taking part in AT&E. For 21% (n=58), this was not a concern, and 56% (n=156) found it a concern, but it did not stop them from partaking. Being able to keep clean was less of a concern, with only 14% (n=38) agreeing that it had or would stop them from taking part. When asked about their concern about the potential acceptability of toilets, 11% (n=32) agreed that this had or would stop them from participating, whereas it was not a barrier for 50% (n=140). Privacy and the cleanliness of toilets were the main reasons behind the concerns about toilets (Figure 1). Not knowing what to expect (33%; n=95) was the main reason for concern around toilet facilities.

Figure 1.

Women who agreed that concern around toilet facilities was a potential barrier to participation in AT&E were asked whether they agreed with five different factors being a contributor behind their concern. The percentage of women who agreed that each factor was a concern for them is shown (n=223).

Managing PH during AT&E had, or would, stop 26% (n=73) from participation. For 61% (n=172), this was a nonprohibitive concern. Only 12% reported that managing their period was of no concern. Thirty-two respondents (11.4%) had not participated in an AT&E trip specifically due to concerns with managing PH or concerns with toilets. Privacy to change sanitary products was the biggest constraint for respondents (29%; Table 2).

Table 2.

Women who agreed that managing their period whilst on AT&E trips was a concern for them were asked whether aspects of period health and its management were a barrier for them (n=280).

If managing your period while on an adventure tourism trip or expedition is a concern to you, is it because of	Yes	No	Percent of all respondents (n=280) who found this issue to be a barrier to participation in adventure tourism and expeditions
Privacy to change sanitary products	70	31	29
Being able to keep/feel clean and fresh while on my period.	69	40	25
Disposal of sanitary products.	67	41	24
That my period would be unpredictable.	57	41	20
The symptoms I experience around the time of my period would affect my performance.	56	94	20

AT&E, adventure tourism or expedition activity.

A subgroup analysis was done to compare the concerns regarding managing PH between the younger and older halves of the respondents (Table 3). The 19- to 29-y-olds were more concerned about privacy to change period products (χ²=7.8; P=0.005), the unpredictability of their cycle (χ²=7.3; P<0.01), and their symptoms affecting performance (χ²=14.71; P<0.001).

Table 3.

Subgroup analysis of the attitudes regarding managing periods on AT&E between the younger (18–29 years) and older (30–40 years) participants surveyed.

	Age 18–29 y (n=88), n (%)	Age 30–40 y (n=192), n (%)	χ² value (P value)
Number for whom managing their period during an activity is enough of a barrier that it has or would stop them from taking part in an adventure tourism or expedition activity	28 (32)	44 (22)	2.68 (0.121)
Number for whom managing their period is a concern to any extent (has not or has/would stop them taking part in adventure tourism and expeditions)	79 (90)	165 (86)	1.29 (0.255)
If it is a concern to you, is it because of
Not being able to keep/feel clean and fresh while on my period?	70 (79)	131 (68)	2.40 (0.121)
Lack of privacy to change sanitary products?	76 (90)	138 (72)	7.8 (0.005)
An inability to dispose of sanitary products?	72 (82)	132 (69)	2.07 (0.149)
The fact that my period would be unpredictable?	62 (70)	99 (52)	7.3 (0.006)
The symptoms I experience around the time of my period would affect my performance?	63 (72)	88 (46)	14.71 (0.001)

AT&E, adventure tourism or expedition activity.

Degrees of freedom=1, n=280, significant at P<0.01. Younger participants, n=88; older participants, n=192.

Correlation analyses were performed in relation to age and concerns (ie, privacy, unpredictable cycle, and symptoms affecting performance; Figure 2). Spearman's rank correlation coefficient r_s was calculated by allocating the responses to age groups. To enable equal division of the data between age groups, the 4 data points for those aged 18 y were omitted. The alternative would have been to omit data from those aged 40 y, but that would have involved omitting 16 data points. For both unpredictable cycle and symptoms affecting performance, there was a negative correlation between increasing age and the variable being a barrier: r_s=0−0.93, P=0.001, and df=9 and r_s=−0.78, P=0.01, and df=9, respectively. The negative correlation between concerns around privacy and age was not significant (r_s=−0.71; P=0.13; df=9).

Figure 2.

Correlations between the frequencies of specific period health concerns and age. The subgroup of survey respondents who rated managing their period health as a concern during AT&E (n=245) were asked to rate five aspects of period health according to whether each aspect was an underlying factor for their concern. For the three factors where Chi-squared analysis showed a significant difference between the older and younger halves of the population, correlation graphs were drawn and Spearman's rank correlation was calculated, to investigate whether there was a significant age-related trend. Panel (a) concerns about privacy to change period products. r_s=-0.71, P=0.13, df=9. Panel (b) concerns that their period would be unpredictable. r_s=-0.93, P=0.001, df=9. Panel (c) concerns that their associated symptoms would affect their performance=-0.78, P=0.01, df=9.

The 82% of participants (n=231) who had previously taken part in AT&E were asked about their previous experiences and what strategies they had used to manage their periods during trips (Table 4). Sixty-eight percent (n=156) wished that they could have changed the timing of either the activity or their period because of period symptoms. Of these, only 42% had previously used hormonal contraception to delay their period to ease participation in AT&E.

Table 4.

Participants who have participated in AT&E were asked about the strategies they have used to manage their period health during their trips.

Question	Yes (%)	No (%)
Have you ever taken part in an expedition or adventurous holiday/activity?	231 (82)	47 (17)
Questions asked only of those who have answered yes to having taken part in an adventure tourism activity or expedition (n=231)
In relation to your previous experiences on adventure tourism and expeditions, have you
Wished that you could change the timing of the activity or your period because of the symptoms you get with your period?	156 (69)	69 (31)
Experienced anxiety about managing your cleanliness, but it has not stopped you from participating?	150 (65)	75 (32)
Experienced discomfort from your chosen sanitary product (eg, chaffing from towel)?	102 (45)	120 (53)
To manage your period, have you
Used hormonal tablets to delay your period?	105 (45)	122 (54)
Used a different disposable sanitary product from your normal product?	63 (27)	160 (71)
Used an intrauterine system (coil; eg, Mirena) to avoid your period?	47 (20)	176 (78)
Used a menstrual cup?	40 (17)	181 (80)

AT&E, adventure tourism or expedition activity.

Two hundred and thirty-one (82%) of respondents had previously taken part in an expedition or adventurous holiday. Strategies used to manage their periods whilst away are ranked from most to least popular. Where the sum of percentages is not 100, the question was not answered by all those who had been on an expedition.

When asked what sources of information they had used to explore managing PH on AT&E, talking to peers was the most common (62%), followed by family (35%) and general practitioners/nurses (33%). The Duke of Edinburgh's Award website has advice for managing PH on an expedition; only 1 of the 172 of those surveyed who had taken part in the award scheme had used this page. Only 10% (n=29) of the 280 menstruating females surveyed agreed that their school education had given them enough information to manage PH in an AT&E environment.

Discussion

The aims of this study were to establish whether FH concerns are a barrier to participation in AT&E, and if so, for what reasons. The main findings were that a quarter of females surveyed would not participate in AT&E if there was a complete lack of toilets. Twenty-five percent agreed that managing PH while on AT&E had, or would, stop them from taking part. Concerns about managing PH specifically has stopped 11.4% from taking part in a specific activity previously. Managing PH was of no concern for only 12% of those surveyed.

To understand the extent and reasons behind how PH represents a barrier, the reasons behind the above-mentioned concerns were explored. Privacy and cleanliness were the main drivers behind concerns regarding toilets being a constraint. For a third of participants, the concerns were due to not knowing what to expect. Only 13% of those who had previously been on AT&E had used a she-wee device. Further exploration of the practicalities of these devices is a priority identified by the US military because females are known to limit fluid intake to postpone the need to urinate in the field,^10,18 increasing their risk of dehydration and urinary tract infections.

There is an information gap regarding managing PH during AT&E; thus, 14% of participants were unable to find sufficient information. The main concern around PH was privacy to change products. When searching for advice, as if the author were considering these issues, only 1 website with relevant advice was found: the Duke of Edinburgh Award's website.¹⁹ This suggests bringing a flannel skirt on expedition to wear while changing period products. This page is only 3 y old, probably explaining why only 1 participant surveyed had used it. It is encouraging that organizations are recognizing the need to provide this information, but we question whether the advice given would be acceptable to young people or indeed whether the advice has the effect of normalizing PH or adding to the stigma. Only 10% felt that school sufficiently prepared them for managing PH on AT&E. Education on PH in schools must improve. These findings are in keeping with the known gap in education given to females regarding PH.^4,12,20 Studies asking females what information they lack are needed because they will allow organizations and industry to give relevant advice. AT&E providers could give information early, explaining facilities and privacy (eg, a webpage might explain that the route has good foliage and that hence privacy is easy to find). This might be particularly pertinent for females from certain cultural backgrounds.

Concerns around keeping clean during their period and disposal of period products were found in a quarter of those surveyed. Females are known to perform better in all-female groups, which is generally attributed to a less competitive environment.^3,9 It is plausible that a more open culture to discuss FH also contributes to this fact. When briefing expedition participants on how human waste is to be disposed of during a trip, it might be useful to mention period products specifically to normalize this topic for the whole group. Suggesting the use of either a sealed plastic container or specially designed bags²¹ may help individuals to visualize this in practice. Normalizing period language and opening the conversation will support the psychologically safe environment females need to perform at their best.⁴

Twenty percent of those surveyed had concerns around period unpredictability and the effect that associated symptoms might have on performance. These concerns were greatest in the younger population (20–30 y), showing a strong negative correlation with age. This correlation may be explained by the greater cycle irregularity and more bothersome associated symptoms,⁴ or it may be due to increased knowledge and experience in the older participants. Alternative explanations are that the older group may have a higher rate of menstrual suppression, either pathologic or medically induced.

In the United Kingdom, only 20% of females feel comfortable discussing PH with a teacher or coach.⁴ FH remains a taboo subject, with females putting up with mental or physical suffering due to shame or fear of judgment.²² If AT&E providers, both organizations and individuals, are equipped and willing to openly discuss PH on expeditions, culture will change. Engagement with strategies such as the Let's Call Periods, Periods campaign²³ will facilitate change. The Duke of Edinburgh Award's webpage regarding PH on an expedition suggests that participants speak to their team as a strategy to help during the trip. To do this, the individual needs to feel safe.⁴ The group, including the guide or medic, needs to know how they might support the individual. Each female will have different needs and symptoms. Lessons may be learned from the Swedish military recruitment campaign¹¹ that tackles these issues publicly and acknowledges the knowledge gap that exists across the sexes.¹¹ Period Proud Wales²⁴ and the social enterprise hey girls²⁴ provide myth busting, but currently these sites do not contain information on PH in remote environments.

Only 42% of those who wanted to change the timing of their trip or period had used hormonal contraception to delay their period. This study did not explore why they had chosen to avoid these methods (eg, lack of knowledge, dislike of using hormones, or concerns about side effects), but ideally they would like to have delayed menses.²⁵ This is an area for further research.

Limitations

This study did not explore individuals’ experiences of using period products in different extreme environments (eg, polar versus desert). Each environment has different considerations that might affect which period products are most appropriate. For example, changing a menstrual cup might be challenging in a polar environment, and we suggest that period pants may be more practical because they need changing less frequently. In contrast, in a jungle, the focus might be infection risk and the difficulty of keeping the skin dry. Further work should explore these issues. Additionally, the survey did not ask about different AT&E activities that also might influence product choice—for example, long-distance cycling, where sanitary towels can cause disabling chaffing.¹⁴

Most individuals who participated in the study had taken part in AT&E (82%), which provided good insights into their experiences. The chosen sampling method meant that the study did not reach many individuals who had not participated in AT&E (ie, those who are hypothesized to have more concerns regarding PH). In addition, it is hard to engage females who have not participated in AT&E with a survey about a topic that likely does not interest them. Targeting females in their late teens and early twenties, because this is the age where drop-out from exercise occurs,^1,4 would have strengthened the study, but it is difficult to obtain ethical approval to study young people. Because there are so few data on this subject, however, the population surveyed is reasonable because it has enabled a first study that has identified gaps in females’ knowledge and the literature.

Although the survey was distributed within workplaces, it also was distributed via a cascade of personal contacts on WhatsApp, which included some participants from non-UK countries. The use of chain sampling²¹ as a method of recruiting participants has likely contributed to the bias toward females who have participated in AT&E because we (who both distributed the survey) are both expedition doctors and also likely contributed to the skew toward older ages. With the given timeframe of this unfunded study, this was the most practical solution to recruit the numbers needed. Further research involving perimenopausal females is needed because this population was not included.

Minimal demographic data (age only) were collected, to minimize the survey length, with the aim of increasing the number of completed surveys. Future studies could explore whether there are differences in females’ opinions between race, culture, geographic location, and educational level. With regard to the strengths of this study, the uptake for this survey was high (n=281), and no incentive were offered to complete it. It is therefore possible to reach statistically supported conclusions from the data. The study has good external validity for participants who had previously participated in AT&E but is less valid for those who had not.

The survey design in this study was of variable quality. The first section of questions relating to social constraints used a 5-point Likert scale, providing a direct comparison with Doran's thesis.⁸ The original intention when writing the questions regarding FH was to design the questions with a 5-point Likert scale because, first, this design enabled a comparison of the health-related constraints against the social constraints and, second, these scales are recognized as a reliable method for collecting usable survey data.²⁶ As the questionnaire was developed, the focus became more clinical using a 3-point scale: “Yes, enough that it has or would stop me taking part,” “It is a concern, but it has not stopped me from taking part,” or “It is not a concern.” This provided clinically relevant data; that is, the findings that an expedition medic would be concerned about are the constraints that participants, or those considering a trip, find prohibitive or will disrupt their performance and enjoyment on a trip. This 3-point scale, however, has likely introduced a central bias tendency,²⁶ potentially limiting the study's ability to explore the degree of the constraints for participants who, for example, participated in AT&E but who had a difficult time managing PH.

This study suggests that AT&E providers should offer environment- or activity-specific PH advice for staff and participants, particularly where organizations target those new to AT&E. It would be interesting to survey knowledge among primary healthcare workers who may encounter 1 of the 32.8% of females who use primary care as an information source. Given that there is no information in core textbooks,^15,27 it is hypothesized that primary care workers’ knowledge is poor.

Conclusions

FH concerns are a barrier to participation in AT&E. For a quarter of the surveyed population, toilet facilities and PH were drivers underlying lack of participation. More than 10% of females in this study had not participated in an activity purely because of PH concerns. Although the demographics of this group are unknown, it is plausible that this finding is generalizable. This work provides insight into further areas for research, as suggested throughout the discussion. Development of resources addressing FH for AT&E would be beneficial. Inclusion of FH considerations in core academic texts for expedition and wilderness medicine is needed.

Supplemental Material

sj-xlsx-1-wem-10.1177_10806032251332281 - Supplemental material for Are Female-Specific Health Concerns a Barrier to Participation on Expeditions or Adventure Tourism?

Supplemental material, sj-xlsx-1-wem-10.1177_10806032251332281 for Are Female-Specific Health Concerns a Barrier to Participation on Expeditions or Adventure Tourism? by Jasmine C. Winyard and Laura McArthur in Wilderness & Environmental Medicine

Footnotes

Acknowledgments

We thank Emily Shepherd, who corrected spelling and grammar.

Author Contribution(s)

Jasmine C. Winyard: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Writing – original draft; Writing – review & editing.

Laura McArthur: Investigation; Methodology; Project administration; Supervision; Writing – review & editing.

Data Availability

All data generated or analyzed during this study are included in this published article (and its supplementary information files). For the purpose of open access, the author has applied a Creative Commons Attribution (CC BY) license to any Author Accepted Manuscript version arising from this submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval and Informed Consent

This study was approved by the University of Exeter's “Overarching Ethics Certificate for Postgraduate Taught Masters Independent Research Projects of Low Risk Typology” (reference number: Ethics application 148/23/04/41), Research Ethics Committee (approval on 26 April 2023. All participants provide written informed consent prior to completing the survey.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Materials

Supplementary material associated with this article can be found in the online version at

ORCID iDs

Jasmine C. Winyard

Laura McArthur

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