Title: MENSTRUAL HEALTH AND HYGIENE AMONGST ADOLESCENT GIRLS AND
WOMEN OF REPRODUCTIVE AGE: A STUDY OF PRACTICES AND PREDICTORS,
ODISHA, INDIA
Version: 1 Date: 09 Aug 2023
Reviewer's report:
Overall comments:
The study is designed so as to provide results that are valid. However, in this process, they
have only identified known socio-economic determinants related to individual identity such as
education caste, religion etc. none of which are modifiable in the short run and therefore offer
no guidance for policy or programmatic intervention.
In addition, if KUSHI program offers safe sanitary pads to girls in schools, then this should
have been a distinct variable in the quantitative analysis to see if availability changed practice.
However, this distinction or even sub-analysis has not been attempted.
It therefore does not add to the body of excellent work that exists on menstrual hygiene
maintenance in Odisha or even within India. That does not foreclose the option for publishing
with a systematic effect at identifying and including modifiable factors that may influence the
maintenance of menstrual hygiene.
Specific Comments on the paper
Lines 129-144:  The authors have said that IDIs, FGDs and KII were conducted. However, the
specific role of each of these methods in the mixed methods research is not clear. The specific
purpose for each method needs to be made clear.
Moreover, the KIIs do not seem to have been used in the analysis. As the KHUSHI program
is implemented, it is important to note the variation across school going girls and non-school
going girls. While the study has included this, it needs mention in this section too.
Line 130: Interview schedules are usually very rigidly structured and used in quantitative
research. How were these used in IDIs and KIIs?
Line 136: Explaining what is a sadar block in brackets would help.
Lines 162-172: How were knowledge and practice associated? If you used the first eigen value,
how many of the 25 variables of knowledge and practice loaded on to the first PCA eigen value?
What dimension did it represent and what extent of the overall variation did it explain?
Line 185: How did you organise the quantitative and qualitative findings and why was it
organised in this way?
Lines 190-191: Most of the participants were Hindus (96%) followed by Christians (2.2%) and
Muslims (1.6%).
Does this match the religious profile of Odisha in keeping with at least Census 2011 which is
available?
Section on results has been organised into themes, apart from the socio-demographic profile.
How did you organise the quantitative and qualitative findings and why was it organised in this
way? This needs to be mentioned clearly as there is no clarity on the underlying study design
for this mixed methods study.  Please see Cresswell J W and Plano Clark VL, Designing and
Conducting Mixed Methods Research, Sage. This will enable the authors to situate their mixed
methods study design.
In the results section, the authors use themes to describe the results. Themes use both qualitative
and quantitative data. Therefore, it might be useful to introduce the method of organising the
results using themes in the methodology section.
It is likely that the qualitative analysis identified the themes (particularly IDIs with menstruating
women and from the FGDs the adolescent girls) but this needs to be explicitly.
Lines 283-291: The impact of age is what could also be reflected as KUSHI is only available
in schools.
Why is the intersection between age and preference (When KUSHI does not provide) not
mentioned here?
Lines 299-304: This needs to be explained as given menstrual taboos within households,
menstruating women were not allowed to bathe in the same spaces as others. They were provided
with a limited amount of water to use other sites for bathing making it difficult for them to access
additional water needed during menstruation.
Lines 376-389:  The authors describe the association between education, income etc with
menstrual hygiene. This is indicative of the association of SES with menstrual hygiene. None
of the variables are modifiable. Therefore, it would be better for the analysis to focus on the
modifiable factors such as access to sanitary pads, willingness to use sanitary pads (if there is a
taboo), having access to the means to dispose sanitary pads etc as factors demonstrating variation
in menstrual hygiene maintenance.