Title: Prevalence and factors associated with unmet need for menstrual hygiene management in
six countries in Sub-Saharan Africa: a multilevel analysis
Version: 1 Date: 14 Feb 2024
Reviewer's report:
This manuscript reports on the prevalence of self-reported 'unmet needs' for managing
menstruation in PMA2020 data from six countries in sub-Saharan Africa, and describes socio-
demographic and WASH facility predictors of self-reported unmet needs.
It is great to see this data articulated and pooled across countries. However I have a number of
concerns about the manuscript.
My key concerns  are:
- The use of past research seems haphazard and doesn't reflect the current knowledge in the field.
Many citations seem inappropriate for the statements they support, and key literature is missing.
- There are a wealth of existing papers that have used PMA2020 data to investigate menstrual
health/hygiene. Authors have not adequately engaged with these, or indicated where they are
referring to papers using the same data as they are using (i've highlighted some more of these
below).
- The analyses do not follow PMA2020 analytic recommendations for use of the data - they do
not appear to account for the PMA survey sampling design - but instead impose an extensive
series of clustering. Without accounting for the PMA sampling the data is no longer nationally
representative.
- The outcome variable used is not adequately described  (and thus not correctly interpreted).
In the PMA surveys the question is “Is there anything else that would help you manage your
menstrual period that you do not usually have?” NOT, as reported in the paper specifically asking
about "resources, materials or changes in environment" - Further the responses to this question
include multiple categories including things that go beyond what the authors outline here (such
as "knowledge" "money" "pain medication" ) - it was quite a non-specific question - and there
was scope for respondents to indicate other needs (although as outlined in other papers given
the focus of preceding questions on blood management the extent of this was probably more
limited), and so the results really need to be interpreted in the same way.
Smith et al 2020 for example, looked at this data and extracted only unmet needs related to
menstrual products to look at associations with socio-demographics and product use. https://
www.mdpi.com/1660-4601/17/8/2633
The Smith paper, and this paper, ask different research questions - but there is significant overlap
in the use of the same data sets and some variables - so the authors need to closely engage with
this work.
- Similarly Rossouw and Ross in 2021 published on PMA data looking at socio-economic
inequalities in MHM - with a very similar research question to this paper. They used different
PMA variables to construct their outcome indicator of MHM need (engaging with the questions
capturing menstrual products and the characteristics of menstrual spaces,). Again given the
considerable overlap between this study and the authors' manuscript -careful consideration and
engagement with this past work is needed.
- Authors have also not noted the sample considerations given the inclusion
of menstruating women only in the PMA sample: https://www.tandfonline.com/doi/
full/10.1080/09688080.2018.1484220 - this paper included multiple PMA investigators, and
was used by the JMP to shift their eligibility criteria to 6 months rather than 3. Again, if using
the PMA data is it authors responsibility to make sure they have engaged with other publications
on menstrual health/hygiene using the same survey program/data sets.
I have provided additional specific notes by section below.
INTRODUCTION
The authors engage with the 2013 definition of menstrual hygiene - which is appropriate given
the focus on the PMA surveys on menstrual hygiene - however throughout the introduction
they also discuss concepts that are more suited to menstrual health. The consensus definition of
menstrual health was published in 2020 - and should be engaged with here as well.
The statement "access to MHM materials and facilities is at the core of challenges" is overstated
- this does not attend to the many other menstrual health needs that are not part of menstrual
hygiene. The citations here are poorly aligned with this statement - the Boosey paper is a small
survey study of a few 100 girls and the Kaur study is about only waste disposal. There are much
more comprehensive systematic reviews of research in menstrual health/hygiene -and there is
nationally representative JMP data across many countries.
The statement that women resort to "substandard and unhygienic products" could be taken
as unnecessary judgement of women and undermining of their choice - Indeed the UNICEF
guidance on menstrual materials highlights clean cloth as a potential preferred absorbent among
women - this matches with JMP data where both cloth and pads are considered having materials.
See also the Smith 2020 paper on this point.
There are existing papers using PMA data on school and work absenteeism reported in these
samples
Krenz: https://www.sciencedirect.com/science/article/abs/pii/S1570677X21000927
Hennegan: https://www.tandfonline.com/doi/full/10.1080/26410397.2021.1915940
MHM is not included in SDG target 6.2 - SDG target 6.2 mentions only "the special needs of
women and girls".
METHODS/RESULTS
- As noted above, authors need to engage with the PMA question and past literature on this, as
well as analysis aligned with the PMA survey strategy.
I note there are some differences between the %s of unmet need and the PMA infosheets on
the data - I expect this is due to adjustment for sampling - e.g., in Ghana the % should be 35
not 34.1% https://www.pmadata.org/sites/default/files/data_product_results/PMA2020-Ghana-
R5-MHM-brief.pdf
DISCUSSION
It is likely that many of the 'community level' predictors around sanitation facility and water
source are also reflective of wealth. Again, particularly since in the data what most women are
reporting is insufficient menstrual materials - much smaller proportions reported unmet need
for facilities (although I expect that the proportion needing them is higher) - and this is seen
in the Hennegan paper that the authors reference where (again PMA data was used, but not
clarified here) to look at the associations between facility type and a different PMA question
about privacy, safety, and cleanliness.
Adequate facilities are needed for 'MHM', but are also part of the definition of 'MHM' that the
authors describe in the background (having an adequate environment to change). Authors should
be cautious of this overlap when drawing interpretations in the discussion.
The statement "this is the first study to assess the total unmet need for MHM" is inaccurate - see
above the Roussouw study - PMA has also reported on these results in their briefs, and the JMP
has given multi-country summary of MHM data.
PMA does not , in itself, adequately capture all unmet need for MHM - and there has been
criticism of the questions used with many improvements in recent years such as the Menstrual
Practice Needs Scale being developed, and the Shortlist of Indicators for National and Global
Monitoring of MHH.