Title: “I stretch them out as long as possible:” U.S. women’s experiences of menstrual product
insecurity during the COVID-19 pandemic
Version: 2 Date: 05 Jan 2023
Reviewer:  Rebecca A. Szabo
Reviewer's report:
Thank you for the opportunity to review this work and thank you for all your work on this
important study and topic. My report and review comes from a place of curiosity and feedback
with a view to clarifying certain things and the overarching aim of improving the work.
Overall this is an exceptionally well written piece of work with almost no language or
grammatical problems. One duplicate word  line 446 page 20 (their). This is an vital piece of
work that should definitely be published but there ares some details missing that would improve
this qualitative study and help clarify some things for me.
I have used the COREQ Checklist to guide my report and review - https://cdn.elsevier.com/
promis_misc/ISSM_COREQ_Checklist.pdf
Completed COREQ Checklist attached.
Domain 1 - Research Team and Reflexivity (item nos 1-8)
6 of the 8 items in domain 1 are not reported; on page 8 it is reported that 2 cis-gender female
research staff conducted the interviews - there are no other details provided about these research
staff. I note also on page 8 it is noted that a two-person research team reviewed the transcripts but
there is no further information provided about them. Suggest adding this detail for the research
staff that conducted the interviews and analysis or provide an explanation as to why it has
not been included. I note authors' contributions at the end of the manuscript provides some
information as to which researchers did what but there is still detail missing and ideally this
should be covered in methods.
Domain 2 - Study Design
Most of this domain was well described and covered within methods. The research design
outlines this qualitative study and its place within 2 other studies. Whilst the conceptual
framework described on page 8 provides some understanding I cannot see where methodology
is described although the choice of analytical method leads me to the assumption this is
phenomenology. I am curious as to what the methodology orientation underpinning this research
was and the worldview of the researchers. Some of this could be covered under Domain 1 in
research team and reflexivity also but is missing. Knowing the methodology and worldview may
answer my next question, which is why was Malterud's systematic text condensation chosen for
analysis? Was it based on methodology and worldview or both of those and researcher expertise
or other? I have no issue with this method or how it has been described and applied but some
understanding of why it was chosen would be useful. Were transcripts returned to participants
for comment and/or correcting or checking.
Domain 3 - Analysis and Findings
The results section is well laid out and described with supporting data but again there are several
items missing. One pet peeve for me is the use of the word emerged on page 9 in results versus.
I prefer generated but appreciate many still use emerged but do wonder about whether the use
instead of the word synthesized was considered given the chosen method of STC? No coding
tree is provided. It would be useful to have either in a table or graphic to demonstrate how the
codes and themes were  generated - using the headings for STC - either within the body of results
or as supplementary materials. I appreciate this may be a word limit constraint but currently this
is missing making it difficult to understand how themes were arrived at and the results read like
any other thematic analysis method was applied not STC per se so again makes me curious as to
why this method was used and so curious to read more detail in the results about its application.
How was data stored and what was used for analysis i.e. qualitative assisted digital software or
manual? This description is missing and would be a useful addition.
Whilst I'm undecided if it would add anything to the paper I note that no where is there a
description or definition of menstrual products although within the discussion there is then
mention of sustainable menstrual products. I do wonder if this is too specific given we would
hope menstrual products would be universally understood but this may be beneficial to consider
adding and I'd be curious if this was defined for participants in which case this detail could
be included in supplementary material. I note the semi-structured guide uses the term sanitary
products but menstrual products is used throughout the manuscript. Curious about this wording?
I  feel the statement that there are few limitations is unnecessary and not entirely accurate.  I
do  applaud the description of the limitations provided. The introduction and discussion both
cover the impact on menstruating students and schools but this study sample is on women >18
years of age. This age limitation is presumably in part a function of the original study ethics
and complexity of including minors in research. This should be included in limitations and
consideration for noting at the end of the introduction given the emphasis (appropriately) placed
on girls and schools, otherwise the inclusion of this background is less relevant for this study.
No comment is made about drawing participants from existing study which may or may not
be significant. Additionally no comment is made about language, literacy and other diversity
including ethnicity and sexuality. I note that the participants had to have already completed the
CHASING COVID  survey in English implying a certain level of written and reading language
proficiency in English. This may well have excluded a number of participants with limited to
no English or limited literacy. I feel this is important to acknowledge within limitations.
I note the description and references of similar work in U.S. and U.K. Whilst acknowledging
this is specifically a qualitative study on experiences of U.S women I am curious as to the
absence of reference to WHO  Statements on menstrual health and rights and The World
Bank Menstrual Hygiene Management Campaign given the inclusion of U.K. data. These
would perhaps add to the work and situate the research, practice and policy implications more
within a global health context. https://www.who.int/news/item/22-06-2022-who-statement-on-
menstrual-health-and-rights
The key recommendations and conclusion are outstanding and well delineated. Thank you for
a well written and thought out study.