“It was a new concept to talk about periods at the state capitol”: a mixed methods implementation-as-usual evaluation of Georgia's menstrual health and hygiene policy

Introduction: Since 2017, 32 US states have enacted policies to increase menstrual material access in schools. Yet, the implementation and equity of these efforts remain poorly understood. This mixed methods study evaluated the implementation-as-usual (IAU) processes of Georgia's statewide MHH policy, the first in the US to establish recurring appropriations for menstrual materials in public schools without mandating their provision. Methods: We conducted document reviews and key informant interviews (KIIs) with state, district, and school-level stakeholders to evaluate IAU. Using framework analysis, we identified and described the core implementation components guided by Quality Implementation Framework and Interactive Systems Framework for Dissemination and Implementation. Results: Georgia's funding-based approach facilitated administrator buy-in, signaled state support, and enabled local adaptation across contexts. Advocacy groups filled key capacity gaps by providing technical assistance, training, and feedback to policymakers, which helped sustain and expand appropriations. However, limited programmatic guidance led to variability in implementation, communication gaps, and menstrual material access across schools. Discussion: Findings illustrate the trade-offs between flexibility and accountability in statewide MHH policy design. Appropriations without mandates can enhance local ownership but require complementary structures for guidance and monitoring to ensure equitable and effective implementation.